Anesthesiology: Vigil over Sleep

Falling Asleep by *tune4jack on deviantART

The ancient Greeks believed that the god of sleep and the god of death are brothers.  In anesthesiology, this isn't really too far from the truth.  Anesthesia is much more nuanced and complicated than simply putting a patient to sleep during surgery.  The science of anesthesiology has been honed over the decades to a delicate art, and is now one of the most regulated and safest branches of medicine.

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There are several distinct steps in anesthesiology:

1.  Pre-op: The anesthesiologist reviews the patient's medical record prior to surgery.  They will meet the patient and assess their airway (mouth and throat) as well as veins for IV access.

2.  Induction: The anesthesiologist induces sleep in the patient through one of several methods.  The most common are IV induction with propofol or inhalation induction with sevoflurane.  Once the patient is induced, the patient is typically intubated to protect his airway, paralyzed so the patient won't move during surgery, and given pain medication.  Throughout all of this, the anesthesiologist monitors the patient's vital signs closely and additional IV access may be obtained.

3.  Maintenance: The anesthesiologist maintains the patient under anesthesia usually with an inhalation agent (e.g. sevoflurane).  Vital signs are monitored for response to pain and surgical stimulus so medication can be given accordingly.  Breathing is monitored because it must be actively maintained by a machine while the patient's paralyzed.

4.  Wake-up: At the end of surgery, the anesthesiologist must reverse everything done to the patient (except the pain medication).  The patient's paralytic is reversed, anesthetic agents are turned off, and the patient slowly wakes up.  Vital signs are close monitored to assess the stage of anesthesia the patient is in, as extubating (removing the intubation tube) too early could be dangerous.

5.  Post-op: The anesthesiologist follows the patient to the post-op area and monitors for a few minutes during hand-off to the nurses, making sure the patient breathes adequately and pain is under adequate control.

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Most people go into anesthesiology because they enjoy 1.) procedures, 2.) taking care of patients in an acute setting, 3.) don't want to deal with the patient's chronic/social issues.  A select group of anesthesiologists pursue a chronic pain fellowship, turning heads on much of what likely drew them to anesthesia in the first place.

I've had the privilege of observing acute and chronic pain services in pediatric patients.  This particular acute pain service controls all PCAs (patient controlled analgesia) and epidurals in the hospital, and are the ones who wean patients off IV narcotics and transition them to oral narcotics and then wean them off altogether.

The chronic pain service was a different world entirely.  Each visit took up to 90 minutes and is conducted with a psychologist.  Pain is addressed in a multi-factorial manner - approaching it from a psychological, behavioral, and medical perspective.  A treatment plan may include CBT (cognitive behavioral therapy) to learn coping mechanisms to deal with/mentally lessen the pain, rehab exercises, and pain medication (rarely are narcotics actually given).

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Even though I will not be going into anesthesiology, the things and thought processes I learned will only make me a better overall physician.

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Infectious Diseases: Diagnosticians of the Weird

DISEASES by ~scythemantis on deviantART

Infectious diseases (henceforth called "ID") is one of three hospital services that is consulted when nothing else makes sense, the other two being rheumatology and immunology.  I was specifically on the pediatric ID service and, time and time again, I've seen these three services consulted on a patient when the primary care team scratches their heads and throws up their hands in frustration.

I came into medical school with a strong interest in ID, having just completed a year (out of two) of a Master's in Public Health in a Hospital & Molecular Epidemiology sub-program focusing on microbiology and disease transmission.  It's a fascinating field with strong ties to public and global health.  I think what attracts me most to ID is that you still have to know a little about everything.  Infections don't just affect one organ or a couple organs, it can involve any part of the body and so you really need to know enough about everything that's going on.  The ID attendings I've worked with are some of the most brilliant (even terrifyingly so) physicians I've ever met.

ID is mainly an inpatient consult service, and is thus consulted by the primary care team to help diagnose and treat things that may have an infectious etiology.  There are several things to know about how the ID team thinks:

Trends: ID is all about trends - trends in fever, inflammatory markers (CRP, ESR, etc), cultures, wound healing, etc.  Trends allow an ID team to see if the patient is suddenly doing worse or conversely responding to treatment.  Trends can also clue in an ID team as to whether the patient has something infectious or not in the first place.

Causality: By its very nature, ID seeks to determine a discrete cause for a disease.  They will question the patient/family for any and all exposures to find some clue in the history for why they're even being consulted.  They will go to some length to obtain cultures from blood, cerebrospinal fluid (CSF), sputum, pus, biopsies, etc to determine what organism(s) grow out of it which may be causing disease.

Proper Coverage: ID is fastidious about the drugs it employs for treatment.  The fear and bane of ID is when a bug becomes resistant to treatment (e.g. MRSA and certain antibiotics).  They are infuriated when other services immediately go for the "big guns" - the stronger medications known to treat a microbe - because overuse breeds resistance.  They are also annoyed when other services switch antibiotics too quickly because they don't see an immediate effect or "double cover" the same organism.

A Motley Crew: The ID team can be a mix of people you may not initially expect.  Of course there is the ID physician, but in addition there may be an ID pharmacist who helps dose and regulate the use of antibiotics throughout the hospital as well as microbiology pathologists who look at the cultures for the ID team (and who answer more readily to the ID service than the rest of the hospital).

Know Your Consult: When you consult the ID team (or any consult service for that matter), make sure you have a good intelligent question and reason for consult.  It should never be, "We don't know what this is, the kid is having a fever, please figure it out for us!" or "We think it's this, are we using the right drug?"  Rather you need to make a convincing case why the ID team needs to be involved - also, this is partly why the ID team usually only sees the most severe and/or bizarre cases, haha.

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Ordinary and Exceptional

Fight For Your Life by *darkcalypso on deviantART

On my flight to Chicago to take my USMLE Step 2 CS exam, I sat next to a pre-med.  She saw me open my review book and asked, "Are you a doctor?"  To which my reply is, "I hope to be soon!"

At one point during our conversation while waiting for the plane to take off, she told me a story about how her mom had received a liver transplant.  She had been fine seeing other patients hooked up to lines and machines, but when it was her mom, it was far more difficult to see.  She remarked, "I think one of the hardest things for me when I get to med school is to not be too emotionally attached to certain situations."

To this I replied, "No, it's a good thing to hold on to your emotions."  Emotions are what make us human and is what draws some (hopefully many/most) of us to medicine.  It's surprisingly easy to detach oneself from a situation, that seeing exceptional situations over and over again make them ordinary - but it'll always remain exceptional for someone.  I believe the moment we lose that attachment, the moment we become cold and treat the patient as "just another patient" or a "bag of symptoms," that is the moment we lose our raison d'etre - if you will - for medicine.  It's not called "the art of medicine" for nothing, as the art represents the human side of care.

Once I arrived in Chicago, I was at a McDonald's getting coffee with my uncle when I eavesdropped on a nearby conversation.  A man sat down across from some friends by coincidence.  They asked him how his wife (I think) was doing.  He replied that she's probably alright, she probably didn't have a heart attack and was just released from the hospital, and that they did a big work-up involving an MRI.  The friends gave their sympathies.

A small part of me ran through that in a purely clinical and almost mechanical way.  But most of me stopped to consider how frightening it must've been for this person, their friends, and the patient herself.  This was an exceptional event.  But we in medicine see this kind of stuff often enough that it becomes normalized and even ordinary.  We sometimes become unphased by the gravity of the situation.  Is this necessarily bad?  No, as it helps us stay calm and collected under stressful situations.  But I don't think we should shrug off our emotions entirely, rather we need to acknowledge them openly.

In a moment of reflection and Zen, I think we in medicine should ask ourselves: are we more healer or are we more diagnostician (doubtless we should strive to be equal parts of both)?  Do we let exceptional events become ordinary?  Or do we, despite the ordinary-ness that exceptional events become for us, openly acknowledge that they are exceptional - perhaps the most exceptional - event for someone?

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Family Medicine: A Holistic Balance

Balance by *BlackJack0919 on deviantART

Family medicine is often thought of as a "jack of all trades, master of none" branch of medicine.  And this isn't false.  Family medicine generally can't manage multiple co-morbidities in an acute setting, nor can they do much more than simple in-office procedures, nor are they as aggressive about pediatric issues or being as detailed/complete as a pediatrician.  But family medicine offers something else: a holistic balance.  During my time with my family medicine preceptor I've seen many things - things that are a natural continuity of what began in outpatient pediatrics.

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Whole Family Care

It was common for my preceptor to see all family members, from the newborn to the child to the parents and even grandparents.  The family physician observes and understands the intimate family dynamics between each member and, at one time or another, hears all sides of the story.  He is then able to practice medicine within the context of the family, utilizing other members where possible if needed.

There is a back-edge to this sword.  Sometimes numerous family members are squeezed into the same exam room to be seen in rapid succession - the child for a cold, the father for back pain, the mother for headaches, the grandma for knee arthritis.  It can be chaotic and frustrating, but one learns to flow through these moments with a smile and an efficient plan.  And through it all, the family gains a deeper trust and respect for the family physician.

Holistic Medicine

Now, when I say "holistic medicine" I don't mean alternative/homeopathic medicine, that which is outside the realm of the mainstream evidence-based medicine.  When I say "holistic medicine," I mean medicine that takes care of multiple aspects of a person's health.  My family medicine preceptor has a saying, "I don't want to give you my medicines if I don't have to.  Let's work on this together and see what you can do first.  Sometimes medicine is necessary, but let's not go there right away."  With every new patient, he'd spend an hour talking to him/her about their life, their concerns, what they want out of my preceptor's care, and lifestyle modifications that can stave off my preceptor prescribing medications.

With many physical complaints, my family medicine preceptor worked with patients to identify the problem and find some home remedies - often in conjunction with medication - to help solve the issue.  He was particularly astute in asking about herbal supplements.  He never dismissed what the patients were taking, but did often caution them as to how some supplements may interact with the medications he prescribed them or how another brand of the same supplement may be more trustworthy.  At times, he even referred patients to complimentary medicine practices such as an acupuncturist.

Work-Life Balance

More so than most other physician I had met, my family medicine preceptor actively stressed the importance of work-life balance.  He often reminded me between clinic visits to take a drink of water or eat a snack or take a moment to sit and just breathe.  He was proud that the flexibility in his hectic schedule still offered him plenty of time at home with his family.  He emphasized the need for us, as health care providers, to maintain a healthy lifestyle and to be an example for our patients.

He had a saying that he often repeated to me, his nurses, and his patients: "Have a good day.  Or not.  The choice is yours."  For many patients he utilized that as a means of motivation to help them get back on their feet and move forward in taking care of their own health - that we have a choice in how we begin each day, that our attitude about health matters.  Whereas in outpatient pediatrics reassurance and education are paramount, in family medicine it would seem motivation and helping patients reach a kind of self-determination is key.

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I understand that there are about as many different family medicine practices as there are family medicine physicians.  And for that reason I count myself very lucky to have been paired with a preceptor whose life values and medical philosophy match so closely with my own - nay, are steps above and beyond what I have come to on my own thus far.

As I move forward with my career, I must continue to take his words to heart and remind myself to slow down once in a while and take care of myself, so that I may take better care of those who need me.

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Life & Death

Life by ~Isilmetriel on deviantART

What an odd juxtaposition.  It was the day of my friend's funeral, the friend I wrote about in my last post.  A part of me demanded that I be there for the funeral but alas I could not.  I was on call.  My last ob/gyn call.  The least I could do was ask my dad to go in my stead.

And on my last ob/gyn call, I delivered and caught two babies.  One of them was to a woman I had seen in clinic almost weekly for the last 3-4 weeks, so she knew me well and was more than comfortable with me delivering her son.

What an odd juxtaposition.  A good friend leaves the world as two little babies enter the world.  Life and death always engaged in a dance.

Backlog: 05-08-12

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And The Dreamer Shall Dream Eternally

Jared,

I don't know who made first contact, you or I.  But I recall that we met the very first day I moved next door to you.  We became friends almost instantly.  Though you were 1 year younger than me, I always considered you my peer and one of my closest friends.

I remember the days when we'd run around in our backyards, absorbed in our imaginary worlds.  From Power Rangers to alien worlds to simply a game of tag, we would sometimes play all afternoon until after the sun set.  I remember you coming by to this one window in the back of my house when I was stuck inside studying.  I'd crack open the window and we'd chat for over an hour; I now marveled that you had bothered to stand for that long.  I remember when your brother, Taylor, and I came back from school one day talking about the alien worlds we had conjured up in class.  You eagerly joined in and became a crucial fabric of that made-up universe.  That day was the birth of your unfinished trilogy, The Ascension.

When I moved to the other side of town after 7th grade, our friendship cooled but never disappeared.  Those were the days of dial-up internet and email was not yet ubiquitous.  Months would go by before we chatted or hung out again.  Whenever we got together, it felt as if no time had passed.  We remained friends for over 20 years, ever since that day I moved in next door to you right before kindergarten.  There's something to be said for that.  Even till recently, months would go by without a word from you but we'd somehow manage to find a way to catch up . . . eventually.

You have always been a dreamer.  You dreamed of faraway worlds and stories.  You dreamed of goals and aspirations.  You had more imagination and creativity than almost anyone else I know.  And you were making your dreams reality.  You were one of the few people who could, with a word, reignite my creativity and passion when I had become too busy with my daily hustle and bustle.  There's something to be said for that.

I had envisioned us growing old together as life-long friends.  I hoped to see you reach the pinnacle of your career, and complete The Ascension.  I hoped to sit with you in retirement, on a beach somewhere, reminiscing of days gone by.  Alas none of this was meant to be.  You are a dreamer, and now you shall dream eternally.

I will miss you.  I will always carry my memories of you with me.  I will carry your passion.  I will not forsake the imagination and creativity of our childhood.  You are, and will always be, one of my closest friends.

Me and Jared at Taylor's wedding.

Jared Adam Radtke

September 19, 1987 to May 1, 2012

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Treatise on the Zen of Music

The conductor by ~Brutalion on deviantART

When one reaches a certain level of proficiency in playing music, one begins to appreciate music on a unique level. It's a sense of connection and "oneness" with music, and this sense becomes an almost zen or spiritual state. It's no coincidence that there has always been a close relationship between music and religion/spirituality.

This treatise discusses the zen of playing a musical instrument and thus experiencing music through the act of playing and creating music. This may be a different experience compared to when one listens to music.

I. The Three Ensembles

There are, in essence, three main ensembles: solo, ensemble/chamber, and orchestra. The musician experiences music somewhat differently in each of these three.

The soloist plays alone, and thus only experiences music through his/her instrument alone. The sense of connection with music is a very personal one, as the instrument becomes an extension of music's soul, the vessel through which it sings. The soloist is in complete control of the music, and thus it is very personal and individualistic.

The ensemble plays in a small group, whether that be two, three, four, or more players. There is no one acting as the locus of the music, but rather, each player must understand his/her role and connect with the music of the others as a piece of a puzzle fits together. The sense of connection with music is a very intimate one, as each player must be attuned to the other players and understand each voice of the music.

The orchestra plays in a large group, with the locus of the music channeled through the conductor. Each section must play as one and every section must obey the conductor for the music to sound seemlessly. The connection with music is one of unity, as each player must be in unison with his/her section, and every section must be one with the conductor who directs the music.

A nice article, Connecting Music and Gesture, explains this idea quite well.

II. The Connection

In Section I above, the phrase "sense of connection with the music" is mentioned in each paragraph. What is this sense? What is this connection? The answer lies in the answer to, "What is music?"

Music is an art medium consisting of sound and silence. There is much variation in the sound - pitch, tone, rhythm, etc. We typically learn music through rote practice of "notes," or written representations of a particular pitch. Through the composer's annotations, we add tone, volume, rhythm, and such. This alone is not what makes music truly music. By this definition, even a robot is capable of producing music.

What is lacking is that human touch - those slight imperfections that add emotion and intent to music. When we play a piece of music, we play it as we interpret what the composer meant it to sound like, but we also play it as we interpret what it should sound like ourselves. The same piece of Beethoven or Dvorak, played by different people, may in fact sound quite different.

It takes time - years of practice - to transition from rote practice and "regurgitation" of the notes faithfully written on the score, to producing music full of emotion and intent. What is it about music that allows us to instantly gain insight into the player's mind? To understand the player's emotion? To appreciate music's intent? There has been much research into this kind of empathy - to how we feel a connection with music.

A great article is here, To Tug Hearts, Music First Must Tickle the Neurons.

III. The Zen of Music

Now that the foundation of the different ways to experience music through playing have been established, and the connection with music somewhat defined, this next section is aptly titled "The Zen of Music." I will admit that this state of zen is not always achieved, but when it is, it can leave one with a sense of awe.

Musicians can speak of "letting the music take over" or "getting lost in the music." Many minutes and even hours may go by unnoticed when one finds himself in this "zone." It is, most likely, a connection to music so close that one is touched by the music on the most personal and intimate level. It is as if the soul has become attuned, and the music is now an extension. It is a sense of peace, completion, and/or euphoria.

This zen is not unlike a sense of spirituality. As in the preamble, it is no coincidence that music and religion were, and are, so closely associated. The sense of connection and oneness can be likened to that same sense of connection some may have with God - it is on par with that very level of closeness.

Conclusion

There are many ways to experience music as a player, whether that is through a solo, an ensemble, or an orchestra. Each of these paths offers a slightly different avenue to connect with the heart of music. This connection, through years of practice and maturation of the musician, becomes strengthened and increasingly personal. Ultimately, this connection transcends to a state of zen where the musician and the music, quite literally, become one.

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At Peace

Inner Peace by *patu- on deviantART

About 1 year ago I was excited at the prospect of returning to UM SPH to complete my MPH in Hospital & Molecular Epidemiology (see post here). It's strange how much things have changed in 1 year. Now I've pretty much decided that I will not go back and finish my MPH, and I'm okay with it - I'm at peace with it.

I didn't come to this decision lightly. I had spoken with family, many friends, and several faculty. I've had people try to convince me to either side. It was the words of my M4 advisor (whom I greatly respect) that clarified my decision. His words to me were something to the effect of:

"I'm going to tell you what I tell residents who're going back and forth on doing a fellowship. A fellowship, like your MPH, is something you have to give it your all and your total dedication. If you're going back and forth like this, ask yourself: is this what you really want? Or is your doubt telling you something?"

In that moment, it became clear. What do I want? What do I want out of my career? Where do I see it heading?

I am obviously still at the beginning of my career, but several things have risen to the top over the last several months. 1.) I want my career to be clinically focused on treating patients. 2.) I want my career to have a public health/community engagement component. 3.) I want to teach students - they need not be med students. 4.) I want a good work-life balance.

None of the above requires an MPH, much less in my highly focused MPH program. When I asked a faculty physician - who basically does what my MPH would've prepared me to do - for his opinion, he emphatically said that I did not need an MPH to do peds or peds ID. What I need for success was talent, hard work, and good networking.

Furthermore, I have no desire (as of right now) to do bench research. There may come a day where I come full circle and find myself back in a lab. And it's not like I'm necessarily giving up on getting an MPH - I may still end up getting it as a part of a preventive medicine or ID fellowship. True I'd have to start an MPH over again from scratch, but being several years removed from it, it actually doesn't sound like a bad thing. But these are all matters in the future, not now.

Will I regret not having finished my MPH now? Well, I'm not the kind of guy who gives up on something half-way through. But things have changed. I have changed (insofar as my outlook regarding my career). I do not regret my decision. I am at peace.

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Year of the Dragon

Happy Dragon New Year 2012 by ~snowslotus on deviantART

January 23rd, 2012. Year of the Dragon. It came and went like any other day (partly because I was stuck in clinic from noon to 8pm-ish seeing patients). But I'm hopeful for good things this year. I foresee a year of change - whether that will be good or not remains to be seen.

Regardless of what's to come, bring on the year. Bring on the day!

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To Save a Life

On Saturday I was volunteering at a student-run free clinic. As an M3, I had an M1 and and M2 under me. They first gather a history and do a preliminary physical exam on each patient before I talk and examine them.

After briefly presenting to me, the M1 and M2 took me to see our first patient. He was a middle-aged guy who had been having nausea for the past 2 months. After talking to the patient for a bit about his history of hepatitis C, I move on to the physical exam. Per my routine, I begin by listening to his heart and lungs. Then I move to his face, eyes, and neck before asking him to lie down for an abdominal exam. I look for every sign of hepatitis and liver disease - jaundice, scleral icterus, spider angioma, etc - none of which he had, which reassured me.

Then I felt something odd. While palpating for his abdominal aorta, I found the edge of it pulse to the right of his bellybutton. I move to the left of his bellybutton and felt the same pulse of his aorta there as well. I move back to the right to double-check. I call out to the M1 and M2 to feel the edges of his abdominal aorta on either side. They confirm that they could feel the pulse on both sides. Eyeing the distance, I ballparked the diameter of his abdominal aorta to be about 4cm. He had an abdominal aortic aneurysm (aka AAA or "triple A").

This was an amazing catch! It's not every day that med students pick up on something so serious, and an AAA is a very serious matter. I ask the patient if he knew what an AAA is, and he said that his father and grandfather both died of AAA's around his age. Coupled with the fact that the patient smoked about 1/2 pack of cigarettes a day, this solidified the diagnosis in my mind. Immediate imaging was warranted to accurately determine the size of his AAA - not knowing its exact size, it might as well be a ticking time bomb inside his abdomen set to rupture at any point inside.

I reassure him that, because he was asymptomatic, he had some time and that we will figure this out. I further counsel him to reduce (and preferably/ideally stop) smoking, as smoking is a huge risk factor for AAA's. Also, smoking cessation can stop an AAA from growing any larger in some cases.

I walk out with the M1 and M2 to find a physician to assess the patient. While they do that, I move on to another pair of M1 and M2 students to see their patient. Later when I touch base again, I was glad to hear that the physician agreed with my assessment and plan. Although a CT scan is the most accurate way to determine the size of an AAA, the clinic didn't have access to "free" CT scans, and so we ordered an MRI for the patient. Really, it's kind of a waste of resources overall because in this case a CT scan is much better and cheaper than an MRI. But, we have to work within the limited resources of the clinic.

Talking to several M3's later, they were impressed that I had caught the AAA. They kept saying how I had, quite literally, saved this man's life. As much as I'd like to believe that, it didn't quite feel like I did. True, I had caught a potentially fatal condition early enough for interventions that would indeed save his life. But the imaging test we had to get for him was expensive and less than optimal, and we had to send him to a nearby hospital to get it done. For all I know, he may never go to the hospital to get the MRI. And even if he did get it, who will follow-up with him? Who will track the size of his AAA? Who will do the surgery when it reaches the dangerous size of 5.5cm? Would he survive long enough to make it to an emergency department if it were to rupture?

There were too many loose ends. This is the limitation of healthcare in the US - this patient is uninsured and we volunteer at a free clinic where continuity of care is fragmented. I may have the knowledge and ability to save this man's life, but he needs regular access to healthcare in order for that to happen. The academic and political discussions about healthcare are no longer abstract. Here is a patient with a life-threatening condition. It need not be so. But he doesn't have access to regular healthcare. Our hands our tied, our resources limited. And so, it remains life-threatening.

I hope he went to get the MRI. I hope it was far less than 5.5cm. I hope he stops smoking. I hope he is able to obtain health insurance. Right now hope is all I have to save a life. But it need not be so.

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Welcome to Life

Newborn by =bnspencer on deviantART

Welcome to life. I know you're tired and unfamiliar with this world, but open your eyes and see the love that has brought you here. Sleep in the arms that embrace you, linger in childhood while you can, but grow up healthy and strong. You are full of the world's hope and potential - anything is possible! What will you choose to be? You won't remember me, despite me prodding and poking you. But I hope my thoughts are etched deep into your heart: I wish you the best on this journey called life, and I hope you are equipped with the love and the help to get through anything. Welcome again to this thing called life.

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About a month ago, I had the privilege of rotating through the newborn nursery for 2 half-days. I had the opportunity to hold and examine a baby less than 48 hours old. His mom handed him over to me (in my mind practically throwing him at me), trusting me unequivocally that I wouldn't hurt him.

He peeked at me through suspicious eyelids before returning to his tenuous sleep. Of all the people to have examined him in his brief existence, he tolerated me the best - perhaps he liked me best. It's something special to hold a baby and not have him instantly cry at you to get away, but rather to tolerate you in a way that almost says, "I don't like what you're doing, but you're okay so I'll let you."

All the meanwhile the parents watch your every move, searching you for the slightest hint that their baby is not all right. The breath in the air hangs suspended as you move methodically through each motion designed to detect the slightest defect, the slightest indication that something may be wrong. And when you finish and everything is okay, the breath falls almost as a sigh of relief.

I read an article, A medical student experience in the newborn nursery, and it struck me just how true his account and his words resonated with me. I'm not sure I can even adequately express in words what it is like to have a family accept and trust you, a total stranger, to hold their newborn child. It's almost like holding unadulterated hope and potential in your arms - so fragile yet resilient.

My interaction with this child is but a flicker of time in his life ahead, mere minutes out of the potential years he could/will have on this earth. But all the same, it was truly an honor and a privilege to welcome him to life, in my own way.

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A Good Death

Death is something that someone working in the medical field will encounter at some point in his/her career. It's always curious how different people handle death. Regardless, people tend to have a difficult time dealing with death, primarily with "letting go." The questions I've quickly come to ask myself when faced with a patient on death's doorstep include: Is this what the patient would've wanted? Are we prolonging suffering, or are our heroics actually giving the patient another chance at life? Is this a good death?

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My first patient died on my 2nd month of medicine. He came in with a massive stroke. Even if he were to survive, his quality of care would be very poor. Knowing this, the family decided that he should be DNR (do not resuscitate). They kept him on life-support long enough for his son to call their entire family and they flew in from all over to be with him as he died. My attending put the patient on palliative doses of morphine and withdrew all machines. He died some hours thereafter.

My second patient died on my 2nd month of surgery. I had met this patient from the outset. He came to us in clinic with terrible pain - pain that every doctor he had seen up to now had failed to take away. We warned him that the surgery we'd do could have a mortality rate of up to 50% due to his co-morbidities. He understood and wished to either have this pain taken away or die trying. He did survive the surgery but he suffered several complications that involved further surgeries. As my resident foretold one day, "He isn't getting worse but he's also not progressing. If he doesn't get out of here, he will die here." Later that day, he coded and CPR was done for almost an hour before a pulse was found. He was rushed to the SICU (surgical intensive care unit) where he was later found to be in PEA (pulseless electrical activity). The surgeon called his daughter who made the decision to withdraw care that night.

The following morning when the other JMS (junior med student) and I were pre-rounding, we read his death note. The other JMS gasped, "What?! She withdrew care? His family killed him!" I was furious because to me, his daughter saved him from what otherwise would've been a week of agony in a painful limbo between life and death.

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Why did we go into medicine? For many of us, it's because we wanted to help people, to treat people, to cure people. We want to make people better. Death is an endpoint. Death is THE endpoint, and one that some can't accept. We defer the decisions to treat or withdraw treatment to the patient and/or the patient's family (or other power of attorney). If they ask for heroics, we comply. If they ask to withdraw treatment, we comply.

But we could do better by our patients. I read an article, A good death is a right we must fight for, that spoke directly about this. In there the physician agrees that, when there's a real chance, we must do what we can to treat/fix/cure patients. But we also have a duty to ease pain and suffering. Many patients on death's doorstep are in a state of pain and suffering that only death can release them, precisely because we don't have the ability to bring them back towards life to the point where their quality of life would be tenable. We have technology to keep lungs breathing and hearts beating, but we don't have the technology to magically make diseases go away.

That all said, the decision to withdraw care is not an easy one and definitely not one to be taken lightly. There is indeed anguish and turmoil within those who must make such decisions. On the healthcare professional side, we may see the obvious answer as withdrawing treatment. But it's not that obvious to patients and their families, and we sometimes forget that. This video reminded me of what it must be like to be in the position to make that decision:

My Friend Jason. from Shot at The Dark on Vimeo.

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This lead to another interesting and poignant discussion that I came across:

When Doctors Face Death

How Doctors Die

Both of those articles talk about how physicians choose to die. In general, there are no heroics or struggles against death, but an appreciation for a life lived and a peace with death. They choose to die on their own terms in conditions they wish to die in. I'll wager that few people want to die in a hospital. More likely, people want to die at home with their family around them.

After seeing patient after patient suffer in the ICUs, at first a burning fire in defiance of death that later becomes a cool ember of surrender, I've quickly come to understand the profoundness in the words of those 2 articles. After hearing death rattles, after watching a patient on death's doorstep twitch and seize uncontrollably - unable to speak or communicate, after witnessing the pains of recovery from a heroic surgery to buy more time, I've to realize that that's not what I want.

What I think we all way is "a good death." What that is exactly may slightly differ for each of us, but at its core it's likely the same: to die on our own terms in the conditions we wish to die in. Perhaps only after seeing death are we able to truly appreciate life and realize that death itself isn't the worst thing, but rather the conditions surrounding it. We have no control over death. But we often do have control - to a large extent - over the conditions in which we die.

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Pediatrics: Treating Disease, Safeguarding Health

Love is... The best medicine by ~hjstory on deviantART

Compared to either medicine or surgery, peds is yet another world in and of itself. Again, at it's core only the patient population differs from internal medicine. However, children are not just miniature adults. There are many unique diseases specific to kids, and this is true also of adults. Medicine manages disease and surgery fixes disease. But pediatrics treats disease and safeguards health.

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Treating Disease

Most diseases that affect children aren't chronic in nature and aren't due to lifestyle choices. Often, kids get sick at no real fault of their own. When a child gets pneumonia or gastroenteritis, you treat it and it goes away. These diseases aren't "fixed" as kids may get them again later, but they're not something chronic to be managed long-term, just nasty infections (kind of like getting a cold, only much much worse). Thus these diseases are treated.

That said, there are some chronic conditions that kids do have to deal with, most notably being asthma and ADHD - neither of which are results of lifestyle choices. Both of these are heavily monitored and managed by the child's pediatrician, and tweaks are constantly being made with the hope that the child may eventually come off medications altogether (usually in the distant-ish future of young adulthood). More troublesome diseases include Crohn's disease and ulcerative colitis, and these tend to be inherited.

Safeguarding Health

Pediatrics - particularly in outpatient peds - the pediatrician addresses the whole patient. This includes development, diet, exercise, school environment, home environment, exposures, stressors, etc. A pediatric patient is more than a collection of symptoms to be managed or fixed. A pediatric patient is a person in the context of his/her sociocultural environment. Really, this is nothing new or different compared to internal medicine, however, there is a much greater emphasis on this in peds. Pediatricians are well aware that habits (good or bad) developed early on have long-lasting implications throughout life. Thus they endeavor to instill good habits into their patients and their patients' families. As such, pediatrics attempts to safeguard health.

This notion appeals to me on so many levels. When I was on medicine, I saw a patient who was so obese that she got stuck in a CT scanner. I saw another patient who was even more obese, so much so that she was unable to even roll over on the hospital bed, much less walk (it was a wonder how they even got her in the hospital doors). But I see the kids of these patients and they are normal - not obese, maybe slightly overweight, but by all other accounts normal. And I ask myself, "How do those kids in less than 2 decades' time become their parents? Or aunts? Or uncles?" Pediatrics has the unique position of being able to intervene when intervention has the greatest potential impact.

To achieve this requires two key things: education and an emphasis on health, not disease. I read an article (here) where a medicine resident goes through a cardiology rotation and encounters a patient who was "non-compliant" in taking her medications. Apparently no one had educated the patient on her cardiac disease and the importance of taking her meds, they just assumed someone in the past had done so. That moment of clarity revealed a gap in which educating the patient, rather than assuming, would've resulted in better compliance. I read another inspirational article (here) that elaborates on why "being a good doctor is more than writing prescriptions." One of the physician's roles in the community is to inspire better health, not just attend to the sick - important and critical though that is. In pediatrics I see this role in public health played out most prominently. One sees it in vaccines, in telling parents what are good food choices for kids, stressing the importance of exercise, etc.

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Pediatricians work just as hard as medicine doctors or surgeons. The difference, to me, is in how they care for their patients. There is much less managing of disease. There is usually little fixing of disease. But there's a lot of treating of disease and on top of that, there is the role of public health in safeguarding health. There's something more holistic about pediatrics that I had not seen in prior rotations, and it may have been the first time that I treated every one of my patients as a person first and a patient second.

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