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Do Not Resuscitate

He was SO mad at me.  He was sitting in a chair at the foot of the bed facing his wife.  He was wearing his United States veteran baseball hat and his well worn cane was leaning up against his chair.  “Can’t you just wait for our son to get here?!”  He was mad at me and he was pleading with me.

His wife, Helen, would not make eye contact with him and would not take her eyes off of mine.  She was pleading with with me too.  In short, staccato like sentences she said to me, “I’m ready. to go.  He knows. I’m dying.  I don’t want.  my son.  to see me this way.  I’m ready.  to go.”

Helen had come in to the emergency department just about an hour prior.  She was in respiratory distress.  She has end stage COPD (chronic obstructive pulmonary disease). She was recently discharged from the hospital to a nursing facility.  At the time of discharge from the hospital she filled out a MOLST form (Medical Orders for Life Sustaining Treatment).  She very explicitly stated that she is DNR (do not resuscitate), DNI (do not intubate), and does not want positive pressure ventilation (something like BIPAP or CPAP).  This morning at the nursing facility she couldn’t breath.  The facility called 911 and she was sent to me by ambulance.

On arrival her respiratory rate was in the high 40s.  Your respiratory rate right now is probably 12.  She was sitting as straight up as her elderly body would allow, leaning slightly forward on her arms.  She was cachectic, uncomfortable, and struggling for air.  We call this the tripod position- if you know someone with asthma, watch their body position when they are having trouble breathing.  She was using every possible accessory muscle- the muscles in your body that help expand and contract your thoracic cavity when your lungs need extra help.  You could see how hard she was working by simply looking at her sternocleidomastoid, a muscle on the side of your neck.  Her oxygen saturation on room air was 72%.  When we placed her on a nasal cannula at 6L it was 83%.  In a patient with COPD it usually hovers around 90-92%.

As you will hear me say again and again, the mantra of emergency medicine is simple- A, B, C.  Airway, Breathing, Circulation.  Start with the airway.  Anyone who looked the way Helen did on arrival would be emergently intubated.  And if not, she would at the very least be put on BIPAP (bilevel positive airway pressure).  Among other things, BIPAP can increase ventilation, increase oxygenation, decrease airway resistance, and hopefully off put the need for a more invasive procedure, like intubation. Helen was working too hard to breath, she was getting tired.  She was not receiving enough oxygen.  If her sats didn’t raise she’d likely arrest, and without resuscitation, she’d die.

But Helen didn’t want any of this.  She was acutely aware of what was going on.  She had the capacity to make her own medical decisions.  She had explicitly put them in writing.  She ultimately agreed to allow us to place her on BIPAP, temporarily, but now she refused to be admitted to the hospital.

Her gray hair was matted from sweat, but even in this extremis you could tell that it had been cut in a stylish chin length bob.  Her blue eyes were piercing.

And Helen’s husband wasn’t ready to say good-bye.

The BIPAP was a temporizing measure.  If Helen didn’t want to be admitted to the hospital that meant she would go back to her nursing home and die.  They don’t take people with positive pressure ventilation.  And Helen knew that.  She was ready.

Her husband was acutely aware of this as well.  “You can’t just send her out there to die.  You can’t do that. You are a doctor.  You just can’t do that.”  Tears were welling in his eyes.  “I need my son.  I need him for me.  I don’t know what I’m going to do.  We’ve been married for 61 years.”

Tears were welling in my eyes, too.  I don’t want to do that.  I don’t want to send Helen off to a nursing home to die.  But I also have to do what she wants.  He begged and pleaded with me to just keep her in the hospital until her son arrives.  He lives in Arizona.   He won’t be here until late tomorrow.  I wish I could.  I really with I could, I tell him.  But I have to abide by Helen’s wishes.  “I understand your pain, I understand your wishes.  If I were you I would want the same thing.  I would want my family here.  And as much as it hurts me, Helen has made her wishes explicit.”

With the help of my social worker, case manager, nurse, and in conjunction with Helen, her husband, and her by phone her son, we all came to an agreement.  Helen would be admitted to the hospital on hospice.  She took off her BIPAP mask.  She was to be admitted to the hospital with comfort measures only.  Her husband knew this meant she may die, and may die very soon.  But he agreed to it.  We took her off all of the beeping monitors.  We were no longer checking her oxygen saturation, we weren’t monitoring her pulse or blood pressure.  I did give her some medication for her anxiety and pain.

Just before she was to be transported to the floor, about seven hours into her emergency department stay, I went back into her room.  I sat down next to her husband and put my hand on his shoulder.  “I’m so sorry for what you’re going through,” was all I could say.  I was again fighting back tears.  I stood up and walked to Helen.  I looked directly into her blue eyes and gave her hand a squeeze.  She squeezed back.  I didn’t have any words.

The following day I came in to work and opened her chart.  Helen passed away peacefully that night.  Her husband had gone home to change his clothes.  She passed after he left.  Her son was to arrive in a few hours and would drive his father back to the hospital to pick up her things. Screen Shot 2017-09-28 at 8.22.06 PM.png

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tomorrow will be interesting

I start my life as a attending tomorrow.

I feel pretty much as anxious as I did  that sleepless night before I started my residency. It is a different type of anxiety. It’s different for sure, but it is so obnoxiously there.

I am not as nervous about the doctor part as I was the night before I was an intern. To be clear, I am very nervous about being a doctor (as I am sure, in my chosen specialty, I will always be), but the night before I was an intern, I didn’t even know what it meant to be a doctor.  At least now I’ve been a doctor for more than a minute.

Graduating from residency is emotional, something I will write about at another point.  But one thing is for sure, you make good friends.  One of my closest started his attending gig on July 1.

I asked him how it went, and he told me that for the first 6 hours of his shift he completely forgot how to be a doctor.

I can see that happening to me.

It’s a new place, new people, and for the first time ever, you are on your own. There were many times in residency when we were probably actually on our own, but it didn’t feel that way. At the point where we had been given enough responsibility and trust to be somewhat on our own, we had been there for 2, 3, or even 4 years and, for better or worse, we knew our team. If our attending wasn’t available, we still had seasoned nurses, pharmacists, and even techs who had good clinical judgment, who knew our strengths and weakness in a crisis, who could do good cpr….

So he told me, a 70 F came in after a mechanical fall… no head strike, no LOC, otherwise healthy, currently feeling great.  If she made it past the trauma bay and into the general department, that generally means the mechanism was insignificant and her primary survey was intact. In other words– her airway was patent, breathing/lungs/O2 sats were fine, circulation was functional, her vitals signs were beautiful, GCS pristine. SO, easy peasy, right? Complete a secondary survey.  If she’s over 65, depending on mechanism and other factors more than likely she’ll be getting a head and neck CT, you know this off the bat.  You keep this in mind as you prepare for the secondary survey where you’ll figure out the rest. And as always, you’ll be thorough. Xray an elbow? Arm? Great. Belly tender? CT a/p.

This is our bread and butter.  We trained at the busiest level 1 trauma center in our region.  And on this bread and butter case, my friend could not think. He literally could not decide what xrays to get. If we were back at our home shop, this would have been second nature. This would have been the patient the senior picked up because it would be uncomplicated, allowing him/her to supervise the junior residents as they picked up the more complicated, time-consuming, teachable cases.

But this wasn’t his home.  He didn’t know anyone that worked there.  No one knew him, no one yet trusted him.  This was an entirely new experience.Screen Shot 2015-07-12 at 10.57.10 PM

And with that, I get it.  He is one of our best, and I know without a doubt this woman got the best care possible, but I know better than most– when you are nervous and anxious, and on top of that, OUT OF YOUR ELEMENT, as I have mentioned a million times in the past, your brain just_ stops_ working.

Sigh.

I won’t sleep well tonight.

And tomorrow will be interesting.

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all grownz up

On June 19, 2008, Dr. French Fry was born.

Well, not really, but I was one year into medical school and decided that medical school was an incredible, wonderful, soul-crushing and terrifying experience and that I needed an outlet.  That day, on that first post, I wrote about three promises I made to myself: 1)stay normal, 2) do not become a crazy bitch, and 3) do not turn into a goblin.

Three years have passed, Dr. French Fry is all grownz up.

Tomorrow I start my residency. Tomorrow I  become an intern.  FuckShitFuckCrap.

On the eve of this horrifying day I am going to amend these promises:

1) Stay normal.  Sometimes I think of medical school as a dark brown smelly slop of quick sand.  If you are not watching where you walk you will take one big giant step into a pile of shit that will straight up swallow you.  You will either never emerge, or if you do you will return to the world entirely unrecognizable.  Since complete avoidance is impossible, I spent four years of my life trying to make sure I didn’t blindly fall in. I tried to keep my ties to the real world and when I got about waist deep I was usually able to tug on them to bring me back.  The verdict is still out on whether or not this was a wise decision, but I managed to get the residency I wanted while continuing to lead a somewhat “normal” life.  I fear this will be harder to do in residency, but I’m gonna give it a shot.

2) Do not become a crazy bitch.  Well, I am going to do us all a favor and combine this with #3, do not turn into a goblin.  I will not turn into a goblin if I am able to sleep.  Likewise, I will not become a crazy bitch if I am able to sleep.  I am going to, against all odds, get some goddamn sleep this year*.

3) Write.  I am going to need an outlet. I am going to have some good stories.  I am going to make an effort to document my experience.

* I should probably apologize in advance for turning into a giant crazy goblin bitch.

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medical personnel

Thank fucking god, I thought to myself, it doesn’t sound cardiac, pulmonary, or neurologic.  I think this guy is going to be okay. The nurse next to me asked what I thought.  I looked at her and tried to sound confident but the increase in pitch at the end of my sentence likely gave away my doubt, “a panic attack?” She concurred and suggested aspirin just in case.  Good thinking, I thought, I am so glad you are here.  Aspirin is the first step in cardiac care and has proven benefit.  So I said outloud to the patient and those listening, “Though we don’t think this is cardiac in origin we are going to give you some aspirin.  It’s only precautionary and won’t hurt you.”  So the flight attendant got the aspirin and the nurse gave it to him.

Deep breath.

It all started with the innocent little ding of the seatbelt noise on the airplane.  “Any medical personnel on board, please ring the call bell, your help is needed at the back of the plane.”  Before I had time to decide whether or not I was actually the medical personnel of whom they spoke, my friend in the seat next to me had already rang our call bell, forcefully, four or five times.  Well, I am sure there’s a doctor on the plane, I’ll just go back and see if I can help.

I trail a woman who says she is a nurse to the back of the plane.  When we reach the galley at the back I notice three things: 1) there is a sweaty man lying on the floor; 2) the only two people who have responded to the request for help are me and this nurse; and 3) I am sweating and after that long walk to the back of the plane my face is certainly bright red.

The flight attendant looked at me, are you a physician?  No, I am a fourth year medical student (yes, I emphasized those words), can you tell me what’s going on?

I crouch down on the ground next to the man, ask him his name, and introduce myself as a fourth year medical student.  “Bruce,” he responded.  Okay good, I thought, airway intact.  I did a quick survey, breathing is fast but unlabored, radial pulse is 110 and strong.  Determining what appears to be immediate stability I continue with questions.

And so this, organized as a medical HPI (history of present illness) as I might present to an attending, is what we were able to gather:

50 year old man with a past medical history of asthma and high blood pressure is presenting with shortness of breath. The shortness of breath started about five minutes prior to presentation while sitting in his seat on an airplane, shortly after the initial symptom he felt as if there was mucous stuck in his throat.  This made him aware of his breathing, which subsequently made him extremely anxious with associated feelings of imminent death.  He was diaphoretic, lightheaded, and noted a tingling in his fingers.  He denies chest pain, back pain, nausea, vomiting, loss of consciousness, or numbness anywhere in his body.  He has no history of diabetes, his last meal was breakfast, he had only water on the flight, and took his daily hypertensive medication this morning as scheduled.  His asthma is well controlled, he uses his rescue inhaler one every 3-4 months.  He had one panic attack, one year prior, that felt similar but not identical.

The nurse mentions that she has a prescription for clonazepam, an anti-anxiety medication.  She asks me if she should get it.  Umm, why are you asking me?  I’m a med student.  And why is everyone is looking at me?  Oh. Okay I get it. I am making this decision. I racked my brain for any contraindications.  If this is cardiac clonazepam won’t hurt.  If this is neurologic clonazepam won’t hurt.  If it is a panic attack it will help, shit, even if it’s not a panic attack it will help.  There are no contraindications with asthma, and in this situation with such a low dose I’m really not worried about respiratory depression.  Is there anything else I should worry about?  Fuck Shit Fuck. “Okay, go get it,” I respond. She returns and shows me the bottle.  I nod.

Twenty or thirty minutes have gone by and I crouch back down by the man lying on the floor.  “How’re you feeling, Bruce? Any changes?” “No, feeling a bit better,” he responds. But he looks terrified and his legs are trembling. I tell him that it doesn’t appear that anything acutely dangerous is going on and that I think he is going to be okay.  Most likely this is a panic attack, but with the resources we have there is no way to know for sure and that I want him to go to the doctor when he gets home.  “I am so embarrassed.” Don’t be, I tell him.  I had a panic attack before and I felt like I was going to die, it’s a real and seriously scary feeling. I explain to him that if anything changes, if he starts having chest pain, if he starts having more difficulty breathing, if he feels numb anywhere, I want him to tell me or the flight attendant immediately.

We all stand around for another while, watching Bruce, checking his vitals, trying to think of things to talk to each other about. His pulse is down, his BP is down, he is looking much better. The nurse heads back to her seat. Slowly I start feeling like my old self again. I am left with Bruce and the flight attendant who asks me for help with the paperwork.  I help her fill out the presenting symptoms and vital signs and I see there is a spot to write down the name of the medical personnel.  I remind her, “You know, I’m just a medical student. I am not sure that counts as medical personnel?”

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this is med school

If you have ever wondered what med school is like, this sums it up exquisitely.

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lazylazylazy

On a lighter note, allow me direct your attention to this: compliments.

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i know, i know

It’s been too long.

I have only one excuse: family medicine.  I’d like to tell you that I’ve been terribly busy and working long hours, but that would be a lie. I’ve been bored out of my f-ing mind and incredibly uninspired.

I finish on Friday and shortly thereafter I will give you a recap, but in the mean time I’d like to refer you to one of my favorite blogs.  This is a short post on a tricky and sensitive topic: death.  We have 100% chance of dying in our lifetimes, and end-of-life care, whether it comes at the age of 22 or 99, should be talked about more.  Enjoy.

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