Hope Renewed...


Ms. F lived. She beat the odds. She was found unresponsive at home covered in her own feces, surrounded by flies and maggots. No one knew how long she had been in this state. She was having trouble breathing and was put on a breathing machine as she was transported to our emergency department. Her temperature on presentation was 94.0, her respiratory rate was 40, her heart rate was 130, and her blood pressure was 80/40. She was completely unresponsive, even to painful stimuli. She was bleeding from every orifice except her eyes and ears. Her labs on admission showed a white count of 2.0, a hemoglobin of 5.0, and a platelet count of 10. Her BUN was 255 and her Creatinine was 10! All of here electrolytes were abnormal.

She was infected, her mental status was horrible, she was having trouble maintaining an adequate blood pressure, she required the support of a breathing machine, her kidneys were shutting down, and she was bleeding profusely.

Ms. F has a history of multiple sclerosis and her only other hospitalization had been for renal failure secondary to a neurogenic bladder. It turns out that this time she had also been experiencing decreasing urine output over the prior week or two. She had difficulty urinating and toxins built up that resulted in altered mental status. A CT scan done the night she came in to the hospital showed that she had retained so much urine that she had perforated her bladder.

Ms. F was on a ventilator for ~ 15 days. She received 15 units of blood and platelets over the first 2-3 days she was in the MICU. She was treated with very broad spectrum antibiotics. She underwent bladder repair.


She lived. She left the hospital a few days ago. She has two little kids at home. I met one of them -- a wide-eyed seven year old who will probably never know how close he came to losing his mom.


When she first came into the hospital, I had no idea if she would live. I thought for sure that she would pass away. Her recovery speaks to the strength of youth and the remarkable ability of the MICU nurses to deliver fantastic care.

Cases like hers remind me of advice that one of my surgery attendings once gave me. We had just left a patient's room where he had discussed the pros and cons of getting lung surgery to remove a tumor. The patient had asked my attending how long he had to live. As we left the room, my attending turned to me and said "Never be arrogant enough to think you know how long a patient has. You will always be wrong! Anything you say is a guess... an educated guess but a guess nonetheless."

So much of what we do involves predicting mortality. When a patient asks if he should undergo surgery or when the family asks how likely it is that their loved one will get off of the ventilator, they are really asking what their chances of dying are... And I don't know.

Ms. F was the exception. The next 99 people who come in with her problems will probably die in the hospital within a few days. The question is, do we treat those other 99 people just as aggressively in the hope that they turn around like Ms. F did? Or, do we tell the family that the chances of recovery are so small that they should make the patient comfortable and not pursue aggressive treatment?

The Last Day

I finished my MICU rotation yesterday. As I walked out I couldn't help but think of the failures I had, the people I wasn't able to help.

The 60 year old Boeing factory worker and father of four. He came in with profound hypoxia (unable to oxygenate his blood) and despite everything we did, we weren't able to improve his breathing. He was diagnosed with acute interstitial pneumonitis, a catch-all term that hides the fact that we don't know the cause or the cure. He was completely healthy prior to this hospitalization. He and his wife had been vacationing in San Diego just a few months prior. He died.

The 28 year old deaf/mute mother who had never been in the hospital other than to deliver her baby a few years prior. She also presented with shortness of breath and was soon put on a ventilator. It turns out that she had the flu and her lungs also had been infected with bacteria (staph aureus). We weren't able to help her breathing. She ended up going on the heart/lung bypass machine (ECMO) to give her one last shot. She died.

The 50 year old husband who presented with liver failure due to a disease known as primary sclerosing cholangitis (PSC). He had been on the liver transplant list until he developed an infection and was sent to the MICU. Based on verbal reports, they had actually found him a liver but just a few minutes/hours later, he became sicker, and they realized he had developed an infection. He was taken off the transplant list temporarily, started on antibiotics, and sent to the MICU. He never got a new liver. He was surrounded by family and friends. When I pronounced him dead, his mother looked at me and asked, "Thats it? Is he gone?" to which I could only nod yes. He died.

During my time in the MICU, I took a day off to go interview for cardiology fellowships. As I sat there through the interviews, with my interviewers telling me how impressed they were with everything I had done, I couldn't stop thinking about all the people that I had taken care of the last few weeks that hadn't made it. Its easy to tell myself I did my best and that these people probably wouldn't have made it anyway, but that excuse rings false. I don't like failure -- its a selfish feeling. I want to be better. I don't want my patients to die.

"Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door"
-- from "The New Colossus" by Emma Lazarus (on pedestal of The Statue of Liberty)

I love the intensive care unit. I like taking care of the sickest of the sick. I like working through the pathology, trying to understand the physiology, and utilizing everything science has to offer to give these incredibly sick patients one more shot.

By the time a patient gets into the MICU, they are on death's door. They might be infected, be bleeding, unable to breath, and have trouble maintaining a normal blood pressure -- the sickest might have all of these. We hoist them onto their ICU beds, we remove their clothes, we attach numerous monitors. If they are agitated, we sedate them. We stick them in theirs arms, their legs, their necks, and their chest. We place tubes down their throats, up their rectum, and in their urethra. We give them drugs that have horrible side effects. If their hearts stop beating, we pound on their chest, shock their heart, and give them more drugs. And yet, I love the intensive care unit.

Most of these patients don't live very long. Despite everything we do to try to help, they frequently end up passing away. The mortality rate in our intensive care unit can approach 50%. And yet, despite the torture we put these patients through and despite the sobering final results, I love the intensive care unit.

Why? Why would I love working a place where I fail so much. Why would I want to put anyone through the things I have described above?

I can sum it up best with a quote from the Shawshank Redemption:

"Remember Red, hope is a good thing, maybe the best of things, and no good thing ever dies." -- Andy Dufresne

When patients come to the ICU, they and their family often don't know what they are in for. They might know they are sick but they might not realize just how remote the chance of recovery is. However, they hope. They hope they can overcome whatever it is that afflicts them. Some might call this false hope or even denial. They say that when patients get this sick, physicians should push for advancement of code status -- basically, try to get the family and the patient to withdraw aggressive treatment and accept that they will not overcome the illness. These people argue that treating patients this sick is futile and a waste of medical resources. They maintain that physicians are the experts in all things medical and thus are qualified to tell a patient and a family when further treatment is futile.

While families might not be medical experts, they are the experts when it comes to what the patient would want, what the patient values, and what the patient is fighting for. Maybe, the patient would be willing to go through anything in order to have that extra day at home with his family. Maybe he just wants one more chance and is willing to endure the torture. People have various motives and values and there is nothing I learned in medical school that would make me an expert on what people want. Instead, I tell the patient and the family in explicit detail what doing everything entails. If they want everything done then I do so.

I try not to think about the torture I am putting these patients through. I remember each of my failures. However, I try to focus on those few that do make it -- despite the long odds. The 70 year old with multiple medical problems that had to stay on the ventilator for over 30 days before we managed to get him off. The 40 year old whose heart stopped beating (PEA code) but who was resuscitated and went home with his family 6 days later.

If we succeed and the patient beats whatever illness is afflicting him, so much the better. If we fail, at least we gave him one last chance -- at a terrible cost, but a cost he and his family were knowledgeable of and willing to accept.

I hope my patients get better. I hope I am doing what they would want me to do.

MICU

I am currently rotating through the medical intensive care unit (MICU). My day starts off at 7 am with a morning conference on a topic related to patient care in the intensive care unit. Usually we talk about ventilator management, various treatment strategies in sepsis, or the finer points about hemodynamic management. Yesterday, instead of our usual morning lecture, we had a physician interested in narrative medicine come talk to us about the importance of writing down our thoughts about what we see everyday. Near the end, we were asked to take a few minutes to write about our worst clinical experience. Here is what I wrote:

My worst clinical experience was during my first month of internship and it was in the MICU. There was a patient with lung cancer who had undergone radiation therapy and presented to the hospital coughing up blood (hemoptysis). He underwent a bronchoscopy which did not show any active bleeding. Later that same night -- around 7pm -- one of the nurses came running out of the patient's room yelling "I need a doctor!"

When we ran into the room we saw the patient sitting up on the side of his bed -- leaning on one of the side tables -- with a massive amount of blood pouring out of his mouth. I always think of hemoptysis as coughing up blood, but this was more like a fire hose pouring blood out of his mouth. There was blood all over the floor. While some of us were trying to move the patient so that his left side was down, others were throwing isolation gowns onto the people in the room to protect us from the blood that was spewing everywhere. We could see pallor move down the patient's face. The patient was dead within two to three minutes.

The patient's wife was eating dinner with him when this started. We barely had time to move her outside the room before everything was over. Watching her try to comprehend what had just happened to her loved one was heartbreaking. As I watched his wife cry inconsolably, I felt a tremendous amount of guilt. He had come to the hospital over 24 hours ago. We had done tests and yet the problem had eluded us. Finally, he was in an ICU in one of the biggest medical centers in the country with several nurses and doctors literally sitting outside his room, and we were still too slow to save him.

This is the worst thing I have ever seen and this was the only time I have ever questioned my desire to enter the field of medicine. The feeling of helplessness and the quickness with which it all happened made this a horrible experience.

I would like to think that by working hard in medical school and during training, I would have the knowledge and the ability to at least try to save a patient's life. Even if I was not successful, I could offer the patient a chance. However, all I could do was watch him die.

What Makes A Good Doctor?


Before you can achieve something, you have to know what it is that you are trying to achieve. Thats pretty easy when it comes to some things. For example, a good running back runs for a lot of yards and scores a lot of touchdowns. A good cook creates food that people like to eat. A good salesman produces the most profits for his company. But what is it that a good doctor does to be considered good?

My goal is to be a good doctor but I am not sure what this entails. I was once told that patients judge doctors on the 3 A's (in order of importance): Availability, Affability, and Ability. The emphasis here is that no matter how good you are, being nice and being there are what matter most. The alternative viewpoint is that results are what matter. A good doctor is a doctor that can cure you of whatever ails you. If he or she is nice, so much the better, but this certainly doesn't come into the equation of defining a doctor's quality. Both of these measures of a doctor's quality are from the patient standpoint. If you ask doctors who they consider to be good doctors, they will envariably point to a physician with impeccable credentials, the most publications, the best diagnostic skills, or someone who generates the most profit for the hospital. In short, physicians judge other physicians not on character or medical results but on criteria that are often not even available to the public. Do you know where your doctor went for medical school, residency, or fellowship? Do you know which journals he or she has published in? In a cynical moment, one of my attendings once quipped that "You go into academic medicine if you want to be thought highly of by your fellow physicians and you go into private practice if you want to be thought highly of by your patients. " Maybe there is some truth to that.

In Doctor, Edward Rosenbaum, himself a physican, writes about his experience as a patient. He ends the book by commenting on what he thinks makes a good doctor: Ability and Integrity. In Dr. Rosenbaum's mind, those are the only two things that matter when deciding if a doctor is good. It sounds simple enough but an entire book can be, and was, written on what those two terms entail.


While I try to figure out what being a good doctor entails, I try to follow the following rules that were passed down to me from one of my attendings. Maybe this isn't the key to being a good doctor, but I hope these rules will at least keep me from being a bad doctor:

1) Be honest. At first glance this just means don't lie to others. But, it also means be honest to yourself -- know your limitations and when to ask for help. And finally, being honest means being reliable. If you say you're going to get something done, make sure it gets done.

2) Treat every patient as if they were family. This doesn't mean get emotionally tied to their case so that you can't make clear decisions. What this means is, pay as much attention to detail on each of your patients as you would if they were your family member, and advocate for each of your patients as if they were your loved ones.

3) Have fun. You can't do a good job unless you enjoy what you are doing.

Sounds pretty simple. Be honest, be considerate, and have fun. If it is really that easy why don't we have more good doctors?

NO VACANCY

Imagine that you booked a hotel room for $150/night and when you arrived at your room you found out that you would be sharing it with a complete stranger. You would each have your own bed of course, and the room even comes with a nice thin yellow curtain that can be used to partition the room in half. Both of you would share the same bathroom with the bonus option of requesting a portable commode so that you could conduct your business right at the bedside. Unfortunately, that nice yellow curtain isn't thick enough to block out smells or noises.

Am I the only person who would find such a situation unacceptable? And yet, these are the exact same conditions we subject our patients to when they are admitted to the hospital.

A shared double room is the norm and patients requesting a single room are frequently charged extra. Sometimes patients get lucky and land a single room without having to pay extra but this is usually only happens when the double rooms are all booked.

What's the problem with sharing a hospital room? How about the increased risk of hospital acquired infections? Frequently, patients with communicable diseases aren't identified when they first hit the door. Only later is it discovered that the patient has C. Diff (diarrhea), MRSA (skin infections), or some other super-bug that is resistant to many antibiotics. Being in the same room, sharing a common bathroom, having hospital personnel move back and forth between you and your roommate increases the risk that these infections continue to pass throughout the hospital. This is why once patients are identified with certain infections they are moved into single rooms. However, these isolation measures are frequently only implemented once the patient has interacted with multiple hospital staff and his/her roommate. If we really cared about stomping out hospital acquired infections, we would start by requiring all patients to be in single rooms. Unfortunately, these changes probably won't occur until a patient is afflicted with a hospital acquired infection and sues the hospital because he was placed in a room with someone that was also infected.

The counter argument hospitals will make is that there just aren't enough beds to make such a change feasible. Interesting when you consider that there is enough money to continually build more research buildings and operating rooms. We have enough money to spend billions on research infrastructure but don't have the millions required to insure that the patients don't get harmed by the very hospitals to which they go for help. Of course, building more research buildings, opening more operating suites, and buying more MRI machines increases the revenue of a hospital. Ensuring each patient gets his/her own room only hurts the bottom line.

Pity is a horrible feeling to have

I am currently on the solid oncology service (think lung cancer, breast cancer, colon cancer, etc... basically, anything other than leukemia and lymphoma). I recently took care of a lady that taught me how much my own preconceived notions affect my medical decision making.

When I first met Ms. M, she was clad in hospital garb -- she was barely covered in a faded, wrinkled hospital gown. A large central venous catheter, the size of a number two pencil, was attached to a vein in her neck and held in place by gauze and tape that were covered with dried blood. Her scalp was covered in some places with short, stubbly hair and was completely bald in other places. She was lying in bed staring off into space while the nurse fiddled with the catheter in her neck.

When I walked into the room and introduced myself she gave me a weak smile. She looked like she was about 60 years old. In fact, she was 40 years old. Just a few years ago, Ms. M had been diagnosed with breast cancer. Originally, the cancer was localized to just one breast. She underwent surgery and lived worry free for one year before the cancer returned. The recurrence was confined to the same breast. However, this time she underwent bilateral breast removal. She also underwent chemotherapy and radiation treatment. The worry free period this time around lasted just a few months and then the cancer returned. It had spread to her liver and bones. She was started on a very aggressive chemotherapy regimen. Her body was unable to withstand the side-effects but the tumors kept growing. Currently she is on her third different regimen of drugs. Despite all this, she has continued to live independently and is active at work and in her community.

She had been admitted to the hospital on Sunday after noticing dark blood in her stool and vomiting bright red blood. In the emergency department she had a very low blood pressure and was admitted the intensive care unit. The GI experts were consulted and she underwent an emergent endoscopy of her esophagus and stomach. This study was done to look for a source of the bleed. However, no source was found. Her blood pressure improved and her blood counts remained stable. She was transferred to the regular medicine floor after spending three days in the intensive care unit. This is when I walked in. I described her to the rest of my colleagues the next day as "An older than stated age female with past medical history significant for widely metastatic breast cancer who presented with a presumed upper gastrointestinal bleed and hypotension (low blood pressure)." Based on just my few first words the rest of my team had already formed a picture of this person. They knew, despite anything more I would say, where I was going with this. Our team decided that she had a very poor prognosis. We declined further workup of her bleeding. We focused on making her comfortable and getting her home as soon as possible.

She was discharged from the hospital today. I was about to leave the hospital when I remembered that I had forgotten to give her one last piece of information. I walked into her room and halted. There were two people in the room sitting comfortably in chairs chatting about where they planned to go tonight. I thought I must have walked into the wrong patient's room. Both of these ladies were very well dressed and appeared to be in their 30s. They were both beautiful. Just as I was about to apologize and excuse myself out of the room, I realized that the lady on the left looked very familiar. It was Ms. M. She was dressed in her normal clothes. She was wearing makeup. She was wearing a wig that made her appear to have long brown hair. The faded, wrinkled hospital gown lay on the bed. The lady that sat before me was a completely different woman. I stammered out what I had come to say. We made small talk and then I left. As I walked away from the room I was gripped with doubt. This lady looked great. Maybe we should have kept her in the hospital and figured out why she was bleeding. We should have been more active in our search. She had told me she was active at home and at work but I hadn't really believed it until I saw her sitting there with her friend.

Did the fact that she could cover her head with a wig and make herself look young mean she had any better of a prognosis? Probably not. Did we do anything wrong? Hopefully not. But, would my workup have been different if I had seen the younger looking, well groomed, and seemingly healthier Ms. M the first day? Almost certainly. Ms. M will follow up with her primary oncologist next week. He is one of the better doctors at our hospital and knows her well. I hope I am not just passing the buck.

I can't help but feel guilty about this case even though I don't think we did anything wrong. Ms. M was presented with the options and she agreed with the team that most of the workup could be deferred or done as an outpatient. Why then do I feel that I short-shrifted her? I think I feel guilty because of my own initial feelings of pity. I presumed that his frail looking, sickly woman had little to look forward to. I couldn't have been further from the truth.