Last week while I was in CCU, I had this patient who had a heart attack. He was a middle aged man who collapsed suddenly after telling his son about his arm pain.  He was placed on the Arctic Sun protocol to increase his chances of survival.  Under Arctic Sun, the person is basically cooled down into a hypothermic state for 24 hours, and then slowly rewarmed over 14 hours.  I had read about this in Time a while ago, but it seemed so surreal to me that it was actually practiced.  Most patients under Arctic Sun never wake up, but a few will.  The family was hopeful, and the patient's brother was especially passionate, kicking around chairs in frustration.   

After the first day, we were all waiting in anticipation for the rewarming, during which the patient could wake up at any time.  I was coming back from a meeting when I bumped into the brother and mother in the hallway, who looked worried and frantic. 

     "He's woken up..." the brother said urgently,

     "That's great!" I brightened.

      "Yeah, but he's having seizure activity." 

I didn't know what to say to that.  I thought for sure that the patient must be in pretty good shape if he woke up at all.  They started bombarding me with what does that mean?  Isn't that like a brain attack?  Will he recover?  Will he be brain dead?  I told them I had not seen the patient and didn't know the situation but hearing about seizures in the context that he's woken up didn't worry me so much.  "Thank you so much, that's what I needed to hear!"  The brother touched my cheek, tears in his eyes, and the two of them walked off. 

So I went in to see what was going on.  Turned out, the patient had never woken up, but his eyes were blinking, and his body twitching, rhythmically, like a cuckoo clock.  The eyelids would open and shut, open and shut, nonstop.  Neuro had been consulted, and they thought he was in status epilepticus.  They loaded him with  anti-epileptics, which had to be done carefully because of his dropping blood pressure.  Great, I thought, I had misinformed the family and given them false hope.  I worried more about them than the patient.    They came back later in the night, and the brother asked me what was going on.  Afraid to spread any more misinformation, I told him that he should speak with the resident.  "But I'm asking you, Judy." he looked at me intensely.  But he already knew from my expression that it was bad, and stomped off.   The patient continued to seize all night despite all the medications.  The doctors talked to the family about his code status, and whether they wanted to change it to DNR/DNI.  The patient's 22-year old son was his health proxy, so only he could make the call.  Most of the family seemed to understand the situation and were willing to let him go. The mother was still resistant, and the decision was postponed. 

He went into multiorgan failure the next day.  His abdomen was looking progressively more bloated, and we began to worry about his bowel perforating due to ischemia.  The spikes on his EEG were getting smaller and the waves were reduced to flattened lines. He wasn't going to make it.  When the family came, the mother entered the room, and broke down crying "I can't let go...!"  I couldn't help my eyes watering and I looked upward so that the tears didn't spill in front of the doctor.  During the family meeting, the cardiologist explained to them that there was no hope of his surviving.  The son refused to take on the immense responsibility of consenting to the DNR/DNI, "I can't do it," he said, "I won't."  But he consented to allowing the cardiologist decide for him.

They took him off the ventilator after the family meeting, and within ten minutes he had gone from plump, warm, and pink to white, stiff, and cold.  And like that, he was gone. 

It's so difficult to lose or relinquish something that has become a part of your life and your self.  During my breakup with Michael, there were many moments when I thought "I can't let go...". I watched this mother finally let go of her son, and I know that I can do it too.  We all let go in the end.  We have to.  And for chrissakes, it's not like anybody died in my breaking up with Michael.  

So just a quick update on my life:  I'm a 3rd year med student in my medicine rotation.   I broke up with Michael in December.  I thought it was for the best but it was also really hard to go through.  It is still hard, and I struggle with it.  Anyway, I just went to a palliative care lecture yesterday, our professor advised us to write our experiences with suffering down in a journal.  So...I'm going to maybe start off with one entry here.  My writing has gone to shit since medical school--I have the urge to write in bullet points and high yield sentences.  It has become all about not wasting time. It was hard just to type out the prepositions in the above paragraph.  I wrote "melancholic" for a patient description once, and the doctors were so impressed that I had deviated from typical medical terminology.  I don't think I've used that word since. So this will be a good opportunity to relearn how to write. 

I just rotated through the hematology-oncology unit, and started the cardiac care unit this week.  There have been a lot of patients who died, or were going to die.  The more I see, the more desensitized I get.  I'm afraid of becoming that unfeeling, scientific minded person that only sees patients as disease processes rather than as individuals.  But seeing patients die, or knowing their prognosis is likely death, still touches me.   

While I was on my medicine rotation, there was a patient, I'll call Mr. M.  When I met him, he was lying in bed, a hollowed out skeleton of a person, barely able to breathe on his own.  He was on dialysis because his kidneys had failed, he was on oxygen because he had COPD and had to take a breath between every word.  Sitting up would make him short of breath.  He also had to use a suction device  to suction out his lung secretions constantly. He also had an infectious ball in his lung that was impenetrable to the IV antibiotics we pumped into him everyday.  No surgeon was willing to operate on him and drain this infectious ball because they thought he would die in the operating room.  He was also suffering from diarrhea 15 times a day, and so he spent most of his day lying in his diarrhea before a nurse could come to change him, before shortly having another episode.  The diarrhea eventually resolved, but everything else--the heart failure, renal failure, and basically lung failure--stayed.  This was Mr. M's condition, every day. I often thought to myself that I would never want to live like that; I would rather pass away than be artificially kept alive on dialysis and oxygen, confined to a bed.  I think I would go crazy.  My attending wanted to discharge him to the nursing home because he was going to die probably within 2 weeks, and the hospital wasn't the best place for people to spend their last days.  When we brought it up to Mr. M, however, he panicked. 

"I don't think they have dialysis in nursing homes.  I don't know, I really don't feel comfortable going.  I can't even get up yet, how can I go to the nursing home?  I would die."   

He huffed through the words, and because he was feeling better that day, he actually had enough energy to express his emotion--fear. My residents appeased him and said we would let him go through rehabilitation first and help him recover before we let him return to the nursing home.  I was astounded.  Did he not realize he was going to die anyway?  Was this life not filled with suffering and devoid of any quality?  But Mr. M was scared.  He didn't want to die.

And I think that's one of the things I've taken away from these experiences--some people will cling on to any shred of hope till the bitter end, despite their suffering.  Not all people.  Mr. M's neighbor in the next room was an old man who couldn't swallow, so we couldn't feed him orally because he would aspirate, get pneumonia, then die.   When it came to deciding whether to surgically put in a feeding tube, he said, "by god, I would rather be able to eat and die than to have to go on not eating at all."

This week on the cardiac care unit, there was another patient, Mr. S, who was in his 80's, and like everyone else in that unit, had a lot of heart problems.  One of the most important things that we have to know about for these patients in particular, is their code status--basically, if you have a cardiac arrest, would you want to be resuscitated with chest compressions and the whole nine yards;  and if you were unable to breathe on your own, would you want to be intubated and put on a ventilator.  If not, you were DNR or DNI or both.  Usually there is a hot pink form in the front of the chart that states the patient's preferences.  Mr. S was DNR and DNI, and he coded on Wednesday--he went into ventricular fibrillation, which is a fatal arrhythmia of the heart.  When the doctors searched for that hot pink sheet, they couldn't find it.  So by default, they did chest compressions and defibrillated--shocked him--6 times before he came back.  By then, a nurse found his living will which stated his DNR/DNI status.  But when asked again for confirmation at that moment, he said " I want to live!"  "Are you sure?" the doctors asked.  "Just give me one more shock!" he negotiated.  A few minutes later, he went into ventricular fibrillation again.  He was given chest compressions and his one defibrillation.  And with just that one, he was resuscitated.  He ended up going home the next day to see his dog, then passed away in his sleep the day after.  I can't imagine what it must be like, lingering at the border between life and death, walking that tightrope trying to decide which side to fall. 

It made me realize again how you don't know how you'll feel in a situation until you are actually experiencing it.  Just a few days ago Mr. S did not want resuscitation;  but at the brink of death, he retracted his statement.  It was by sheer luck that he had a second chance and another day to live.  So what made him change his mind?  Fear of the unknown?  It has made me reflect a lot on my own decisions.  I had a car accident two weeks ago during which for a brief moment I thought I might die just before I rammed into the highway divider.  

I had a patient last week who was a 24 year old girl with cancer eating away her pelvis, refractory to all chemotherapy and stem cell transplants.  Based on her records, it was pretty clear that she was probably not going to make it; my residents shook their heads and said "not good."  The cancer was going to be a slow, painful death, compounded by all the toxicities of chemotherapy.  I felt this heaviness in my chest when I walked into her room for the first time.  Talking to her, I realized she was still hopeful and had a positive attitude about her situation despite her constant pain.  She was going to have another treatment in a week, and she would take it from there.   

It was really painful, talking to her, knowing this healthy, attractive, young person sitting in the hospital bed before me, telling me about going to the movies and partying with her friends, was going to die. It was surreal.  What if the roles were switched, and that was me with cancer slowly consuming my body?  How would I take it?  Probbably not very well. 

So this is my world now, medicine. 

Update

 In third year of med school.  Pediatrics rotation.  A bit unreal how little time there is, and it's hard to think that maybe life will be like this.  How did you i-bankers do it???  I get out at midnight sometimes and I feel like I'm going to crash, and I can't imagine having to work until the early morning hours like you guys.  It's been fun, though.  The babies are so cute in special care nursery, and I get to feed them if I have a break once in a while. 

5 year Reunion

Heirloom Tomatoes from Michael's Garden.

So I don't get to party like I used to, and it's been a while since I've been to a club. So I took up mountain biking in Harriet Hollister National Park near Rochester.