How Do I Fix My Head?

I've recently learned that my reading base extends well beyond what I anticipated and probably even wanted (if you feel guilty now.... good :)). In all seriousness though, I cannot reiterate enough that I write for me. Its one of only a few ways I have found to adequately and fully express my jumbled and, at times, incoherent thoughts (as an aside, the other ways once included punching walls, which thankfully God has pacified such aggression). I share what I write - and hence think - because I believe often it can have implications for others, allowing them to ponder a subject they might not have previously - or possibly from a difference perspective. This is not to say I hold in such high esteem what I think and say, but rather I mean to emphasize the value of dialogue sprung forth from differing perspectives - and I truly doubt that you and I hold the same opinions regardless of whether our core values coincide.

One subject that has been on my mind recently is the difference between "comfort care" and "withdrawal of care." First lets be clear, I do not intend to entertain the topic of euthanasia - see Dr. Kavorkian, - which could be construed as similar to the above, but for these purposes will be left for another time. So what has me thinking of death? Obviously it stems from my time in the hospital, but more directly from of a patient I recently cared for. I will be as blunt to say, I think there to be a very distinct difference between these two realms of care. Furthermore, I believe, this difference becomes clouded in the hospital. Is this due to sadism of doctors and nurses? Certainly not. The more likely reason is because such terms are used with great frequence yet not given adequate contextual definitions.

Thus, I will begin by defining exactly what I believe each of the above terms to mean, hoping to stave off any unintentional confusion. First, "comfort care." In my eyes, it is care that aims to provide peace and, as much as possible, pain-free medical management in the setting of a terminal diagnosis. A bulky definition to be sure, but a definition nonetheless. So how then do I define "withdrawal of care?" Most simply, an intentional action of taking away some pharmaceutical or nutritional substance, or device, which thereby the end result is death.

So the difference? Both require actions, on one side for the provision of care - to make one 'comfortable' an action must certainly be taken - and on the other to stop the giving of care. Both have the same end point, death. But the difference, I would contend, is the intention - and therefore mindset - of the action. Having had two patients in the recent past placed on 'comfort care,' I have felt, in both circumstances, the care being provided was less than ideal.

The natural continuation of these thoughts has led me to ponder (not for the first time) how often one medical advancement to prolong our lives leads us to discover another limiting factor. Examples abound, such as better acute heart attack treatment that helped lead to the burgeoning population of heart failure patients. We weren't meant to live forever, this I know. Yet sometimes I feel trapped in an occupation that demands my commitment to ensuring the exact opposite.

Pronouncements, and the like....

I walked into the hospital Monday morning after a much-needed Sunday off, not anticipating - as no one would - that my patient had a stroke hours before leaving him unresponsive. But that is exactly what happened. Discouraged enough, I drudged on to see my next patient, a sweet elderly woman, expecting to be discharged that morning since her recent cardiac procedure was without complication. My heart sank again after I learned she spiked a fever overnight, was short of breath, and had some increased cough. I hoped it was simply a charting error, a poor use of terms, and her history of chronic bronchitis all coalescing to present as some perfect storm, rather than the more plausible explanation of hospital-acquired pneumonia.

That was Monday.

Tuesday brought overnight call - the myth-like 30hr workday that becomes my reality every four days. Tuesday also brought my first pronouncement. Late into the night - about the time you wonder if your supposed to say morning rather than night - I got a text page informing me that my patient had died and I needed to come pronounce him. I don't know how long I stood motionless in the hallway, but I suspect it was pretty close to the eternity it felt like.

I feel a certain level of comfortability with death. I have had a few deaths in the family. I have seen numerous dead bodies in my profession. As a student I accompanied my resident when he pronounced a patient of his. I even spent two months cutting through a dead body four years ago in the name of education. Yet, at the same time, when encountered with death I notice this wave of emotion that perpetually surges through my mind - as if it was something so completely novel to me. I felt those very same emotions once again Tuesday night. I proceeded to my patient's room, walked in, and found him as one would - supine and motionless. I snapped out of my haze quickly enough to perform the necessary steps in a pronouncement, then stood there for another few minutes staring. I don't know what I was looking at, or for, or whatever. I found myself curious of his last thoughts. Was he happy? Was he in pain? Did he know Jesus? Did he even know what was going on?

Surreal doesn't even begin to describe it. This was someone who entrusted his medical care - nay, himself - to me. I couldn't help but feel I had failed him in some way. Was there something I forgot? Could I have done something different? Of course those reading think, "you did what you could, it was his time," "you can't save everyone," or some other trite derivation. But you have no idea what its like. You have never stood next to the bed of a person who used to be your patient.

I was only gone for one day.

Stories From The Other Side

I would hate for this to become little more than a dumpster for my humorous (to me) medical stories, but sometimes seeing an industry from the other side can be quite revealing. Additionally, with my horrible memory for memories themselves, I have to write things down. So that means either handwriting or typing... and for those who have seen my penmanship, you understand there was no decision needing to be made.

I had an elderly gentleman for a patient recently that presented to our ER for syncope (passing out due to decreased blood flow to the brain). Syncope is a rather broad work-up - encompassing neurologic, cardiac, vascular, psychiatric, and metabolic systems as possible etiologies. That, however, is not the point of the story. My patient was 'slightly' demented, by which I mean he didn't really know what was going on around him, but was really nice. Before I met the patient, I was reading through his chart prepping to write my H&P and I came across the ER resident's patient encounter note. Hoping to glean important information from their history and physical (if you know ER docs thats pretty funny) I furiously read through the scribbles. Under the 'HEENT' (Head, Eyes, Ears, Nose, Throat) exam was written, "wobbly jaw." Curious... never heard of that before. So I go and see the patient, finding him hiding under his covers. I call out, "Mr. _____," I'm Dr. Mandichak, one of the residents that will be taking care of you. He promptly answers me - from beneath his covers. The funny part of the story, the guys actually has a wobbly jaw. For whatever reason (probably partly age and dementia) he constantly moves his jaw like he is chewing something, despite the fact he has neither teeth nor food in his mouth. He was henceforth referred to as "Wobby Jaw" on rounds. My hope is to get him and Salty Beans together so the three of us can hang out.

Most recently, I was caring for another elderly patient (why did I do Internal Medicine again?) who had heart failure. She wasn't a particularly nice lady, refusing to speak to me on many many occasions. After she had been in the hospital for about a week getting diuresed - aka peeing a lot - and had a cardiac cath, to assess the ability of her heart to pump, she decided she wanted to go home that minute (essentially a day before we were going to discharge her anyway). After explaining that she was guaranteed to be back in the hospital within a week if she left at that time due to her medical condition, she still refused to stay. Long story short, I did all the paperwork and her ride arrived that evening. As she being wheeled out of her room by transport, she tells the nurse she has cherries and strawberries in the floor refrigerator. Below is the following conversation:
Nurse: Here you are Ms. ______
Patient: Thats just my cherries, where are my strawberries?
Nurse: I didn't see any strawberries in the refrigerator. Are you sure you had some?
Patient: Of course I had some. I brought cherries and strawberries with me.
----Not in earshot of the above conversation and sitting down at a nearby computer, I interject---
Me: Ms. ____, you all ready to go?
Patient: No I'm not ready to go. Somebody stole my strawberries! I want my strawberries!
Me: Hmm, I don't know what happened to them.
Patient: Whose going to pay for my strawberries?! I paid $8 for them!
Nurse: I'm sorry I can't find them them. You may call the hospital comment number to report any concerns you have.
Me: Take care Ms. _____, have a good day.
Patient: I ain't takin care nothin.... you stole my strawberries! I'm gonna get my strawberries!


Ahhhhh hilarity ensues......


My second call turned out to be more dramatic than my first. A patient of mine admitted for Peri-Partum Heart Failure was to be discharged the next day. Well don't you know, that night she had a tonic-clonic seizure. I of course was in the cafeteria at the time finally getting food around 11pm. It was my first experience running through the hospital to a crashing patient as a doc. The only other time I did that, I was still a student and things were flying out of my pockets as I was running. My pager fell off and literally slid 20ft down the hall.... quite embarrassing.