ndab Ah Yes, Medical School: August 2006

Saturday, August 26, 2006

On The Road Again

Ah, fourth year. When the evaluations by your superiors do not even matter. The stress reduces. The opportunities are as wide as the eye can see. And it is also the time you can shamelessly sign up for cake away rotations at desirable vacation cities to have a good time, party, see old friends...and maybe learn a little if you absolutely have to.

Yes, I will be embarking to a different major metropolitan city tomorrow for a four week vacat-err rotation where I will study...umm...I have no idea what I signed up for. I hope to have regular internet access to chronicle what will assuredly be ample amounts of comedy - by the way, it turns out that pulmonary medicine, what I have been doing the last 3 weeks, is completely and utterly humorless, and for that I sincerely apologize - for me to share with you all.

So sit back, relax, and resist all urges to write a comment that goes something like "There's some motherfuckin' medstudents on the motherfuckin' plane!". Thanks.

Sunday, August 06, 2006

Failure

Amid the constant flashing lights, the shrill beeps, the moans, and the persistent alarms, there was one other event that I could always count on every single morning of my three weeks in the medical intensive care unit (MICU): that my first patient (we’ll call her O) would spike a fever, and that no one would have any clue as to why. I picked her up on my first day of the rotation, but O had already been in the MICU for over a week after having had a bleed in her brain, in the hospital for over two months after surviving a severe case of necrotizing fasciitis (that’s flesh-eating bacteria to you). When I first met O, she tried to speak to me but could not do so, the ventilator tube obstructing any and all attempts at verbal communication. Instead, she mouthed the words “take it out” and motioned weakly to the tube with her hand. I explained to her why we could not do so, that she was too weak and would die if she tried to breath only on her own, before walking away to do my work.

The first few days were rough for me, mostly because I had a hard time figuring out what was going on with just about everything. The MICU is a scary place for newcomers, lots of machines beeping, lots of sirens, special tests, sickness. Which is why my daily routine with O was so calming, if only because I could count on nothing drastic changing with her. For an MICU patient, she was, so gloriously, routine. I would check her overnight data, find that she spiked a fever, checked all the labs to confirm that there was still no source, and promise to her that we would try our best and keep looking. The comfort of this routine was made more so because it was just about the only routine thing that would happen in the MICU. After all, these are the sickest of the sick, people teetering on the precipice of life and death on a second by second basis, relying on countless machines, drips, and manpower to keep them alive. But O and I , we were a team, soothed by each other’s routine, reassured by each other’s presence.

Halfway through my rotation, I admitted a 32 year old gentleman with a type of leukemia that was refractory to treatment. He was having difficulty breathing for multiple days, but was well enough one morning to tell me that he was ok, save the sensation that he needed to urinate. I walked away from him, poked my head in to look at O, and proceeded to team rounds. Within five minutes, the nurse ran out of the gentleman’s room and said “He’s not breathing.” Code blue. Chest compressions. Shock. Intubation. He made it through the code, but only after having no pulse for almost eight minutes. The last thing I said to him was, “Do you feel like you need to pee?” A little later I walked by O, noticed that she was more lethargic than previously, and continued searching for the cause of her fevers. I found nothing.

Later that same day, at about the time the wife and two young daughters were saying goodbye to their 32 year old husband and father right before he stopped breathing for good, the team was down in the ER, there to greet a 29 year old gentleman, also with leukemia, and also having difficulty breathing. His girlfriend, a nurse, was at his side, pleading with him to be calm as he tried desperately to express what he did and did not want done to him. Yes to help with breathing, no to invasive breathing tube. Yes to pain medications, no to blood pressure drips. We left the bedside at about the time he defecated on the bed, because we had to go back to the MICU and declare the 32 year old to be dead.

Later in my rotation, I checked up on O. Sure enough, she’d spiked a fever the night before, we still had no clue what was going on, but now she was barely arousable. Sure enough, the 29 year old’s heart, which had been pumping furiously to keep up with his thrashing, eventually gave out. His girlfriend and his family were all at his side. His mother, who surely never expected to outlive her son, was screaming, moaning. Family members poured in, more shrieks. We sat by our computers, which are situated by the bedside for central access, while this young man’s family cried for four hours. Four hours. There was nothing to do but listen.

On the second to last day of my rotation, I peeked in on O, who was at this point almost entirely comatose but who was about to go down for more surgery, because the plastic surgery team that removed the original flaps of infested skin felt they could possibly remove more that might be infected and might be the cause of her fevers. I knew this was going to go well, a success story, one where she’d defeat the fevers, reawaken to life, and no longer need that breathing tube. About an hour later we received a frantic call from the plastic surgeons, who noted that she had a new infection of flesh-eating bacteria, one that probably started as a smidgen the night before but had now melted away much of her left arm. Her arm was going to have to come off if she had any chance of surviving.

Finally, on my last day, I showed up especially early to check up on Ms. O. She was not there. She no longer had a fever. She no longer had a bed. Or a tube down her throat. I never discovered the infection that had been giving her fevers for over a month, only the new infection that took her life, and even that discovery came too late. It ended up being her time to go, as much as it was mine. I did not get a chance to say goodbye, and apparently my arrival missed her departure by a mere 20 minutes.

There is nothing routine about the MICU routine, but I know that it has left me more numb than I would ever care to be, more distraught and afraid of the thought of dying, and more riddled with nightmares of family members weeping, screaming, howling, hugging, and leaving while their sick move onto something else.