Feb 22, 2012


Her vitals are okay to start with. Blood pressure, pulse...they aren't alarming yet. The patient, a young woman transferred from another hospital for higher-level care, looks at me but doesn't see me. Her eyes are glassy, pupils nonreactive. She is sick after an intentional overdose of Tylenol and a "handful" of other drugs. The specialists descend into the room, like flies on a picnic- toxicology, hepatology, transplant surgery, neurology, nephrology, pulmonology, intensive care.

I'm pretty sure there is some graph that directly correlates mortality with the number of specialists involved in your care.

She gets the Tyelenol overdose treatment started. She gets an ICP monitor screwed into her head, poking out like a funny antennae. We learn that she's not a liver transplant candidate, on the account that this was intentional.

She is young, and pretty. The nurse tells me she thinks she looks like Beyonce. I think to myself, maybe, if Beyonce was yellow as a canary. But I can see it too. It scares me a little that she's only a little older than me, and this sick. I don't understand how she could do this to herself. Is this outcome really what she wanted?

Her blood pressure is falling a little today. She looks the same, quiet and nonresponsive. She's not doing well, despite all the treatments and specialists. I didn't expect her to.

I find out that she's got eight kids, the youngest of which is still an infant. I clench my jaw, angry with her, forcing myself to lay my stethescope gently on her chest, and listen. I kind of want to hit her with it. She's got a stuffed bear laying in bed with her, holding a heart saying "Love You Mom." I don't understand how she's made this choice, how selfish it seems to me. I look at her own mom, lost with the idea of raising eight grandchildren. My anger grows.

She is failing, despite maximum blood pressure support. I know she might die soon, and dread the thought of performing CPR on her, dread breaking her ribs with chest compression and giving intervention to a woman that I know is already gone. She is still a full code status, and I am waiting to hear if she will be changed to a DNR when more of her family gets here. I read specialist after specialist's progress note saying "prognosis extremely grim." I know. I worry about the family. Do they know? Finally, later that day, they seem to understand. They change her to a DNR, and the tension in my stomach unknots a little as I watch her monitor.

There is a cart outside the patient's room with a large tray of muffins and cookies, and pitchers of coffee, tea, and juice. I ask the other residents what it is, since I haven't seem that before, but it looks like the hospital food service. I am informed that it is the "death cart."

What? I am stunned.

"It's the death cart" a senior resident tells me. "Once I see the muffins show up I get my death dictation ready, cuz it's gonna happen soon."

Apparently when someone is about to die, the hospital sends up a tray of food and drinks, since often a lot of family is there and they want to stay in the room with the patient instead of leaving for the cafeteria. I am touched that my hospital thought of this. But to the residents, the muffins are a herald, a sentinel sign for the events forthcoming.

I stop in the room to say hello to the patient and her family. Her mom asks me how long they can hold a body in the morgue, and if they have to pay more past a certain point? They are trying to make arrangements. I honestly don't know, so I call up the morgue myself and ask. The morgue guy tells "a few months, if we forget bout em, but most of the time, a week or so. We don't charge no rent for the fridge space."

I don't relay any information besides the fact that she can stay as long as needed. She is starting to feel cold under my touch already.

The nurse pages me, saying she has died and she needs me to come to a time of death and death declaration exam. I'm not sure what this is, and google it quickly, and find a checklist of things to do. I've never seen one before. For that matter, I haven't seen many people die before.

I hope the family is gone. I don't want them to see me do things to their daughter, their girlfriend, and mother, that just reaffirms concretely what we all know. Thankfully, they are out of the room. Some of the muffins are gone too.

I place my stethescope on her silent chest, easily gently this time. My anger for her has evaporated. My fingers don't feel a pulse on her cold wrists. I am scared by the empty look in her eyes, by her stiff tongue and blank expression. I can't unbend her fingers, and her calves are stiff and contracted under my touch. I open her eyes, look at her pupils, and touch a cotton swab to them. She doesn't blink. I shut them quickly, my fingers pulling down her lids, shutting my own eyes too. I tuck her Love You Mom bear a little closer to her in bed, and pull up the blanket. I wonder, is this really what you wanted? Somewhere, are you happy, succeeding in what you meant to do?

And somewhere, a tiny irrational part of me worries that I did it wrong. That I did something wrong, and am sending a live person down to the morgue, that there's some reason I don't know why I cant feel a pulse. That she'll sit up in the fridge and wonder how she got there. Funny, maybe. Irrational, yes. But true.

And, a tiny irrational part of me worries that there is something more I could have done when she came in. But, I know the truth. She was gone when she came to me. I guess that's what she wanted.

Time of Death: 1136.

Feb 17, 2012

Thank You

Here is a story of probably the nicest thing any patient has ever said to me. I wanted to write it down before I forgot, so I can look back at it on the days that I feel like my work doesn't matter, an attending berates me, the nurses undermine my work, or there is a sad outcome. I went into medicine because I wanted to help people. And I thought becoming a doctor was the best way for me to do this- to gain the technical and clinical skills to be helpful. Sometimes it is. Sometimes it feels like it isn't. But, I love what I do, and what I get the opportunity to provide. Sometimes it's easy to forget this, which is why I hold on to this memory, precious and vivid.

I admitted a young woman, pregnant with her first baby, at 34 weeks. She was feeling sick, and her baby's heart tracing was concerning. Both of them looked sicker within the hour, but the attending and I were slow to want to do a c-section on a premature baby. We gave her fluids, and I watched them both closely. Then, the baby's heart rate when down. I called a crash section, and with the help of the OR team, had delivered that baby before the attending even got to the hospital.

There are a few quiet minutes, in between initiating the crash and the quick ride to the operating room and swift delivery. They are precious, my one opportunity to sit calmly with a mother and her loved ones before the chaos begins. I take her hand, and tell her "Everything is okay. Your baby's heart rate went down, so we need to do a delivery now. But, we do this all the time, and can get your baby delivered quickly." Usually the panicked mother starts to cry about now. I let her know gently, "in just a few moments, it's going to get very busy in here, with a lot of people, but that's normal. We just need lots of hands to help. We are going to take a quick ride down the hall to the operating room, and I'll be waiting for you there."

This time was no different. Lots of nurses, a quick ride down the hall, me smiling at her with everything but my eyes covered by a mask. A few minutes later she was delivered, and I was stitching her up, just as the attending arrived.

The gem came later, two days after her delivery, during my morning postpartum rounds. I went to see how she was doing, and she grabbed my hand and squeezed it. She said "I just want you to know...that time you sat talking to me, when you told me how it was going to get busy, but not to worry, because that was normal? That was so calming, and I just wanted to tell you...when I think about my baby's birth, I think of you. My clearest memory of my delivery is you, sitting on my bed, in your flowered hat (scrub cap), holding my hand and telling me what to expect, and that it would all be okay. Thank you."

Thank you, dear patient.

The Light

This is one of my very favorite patient stories.

I am in the ICU right now, working with very sick patients. This 94 year old gentleman came in to us hypotensive and tachycardic, and needed a lot of fluids. We decided to put in an IV in the jugular vein, to allow high volume fluids to go in. I explained what we would be doing, and that he needed to have a drape over his face in order to maintain sterility during the procedure. He agreed, and masked and gowned, I covered him up with the drape and began the procedure.

It was a little dark in the room, with only the flourescent overhead lights on, so the attending reached over and turned on the bright surgical spotlight so I could see better. All of a sudden, under the drape, the old man begins screaming"I SEE THE LIGHT!! I SEE THE LIGHT! OH LORD JESUS DON'T TAKE ME I AIN'T READY TO GO YET!"

"Sir. SIR!!" I reach out and touch his shoulder. "We ALL see the light, sir. It's okay. We turned it on to see better for the procedure." He is wary. I tell him, now we are going to turn off the light, okay? He nods. I then tell him, "sir, we are going to turn the light back on. I just want you to know it's me turning on the light, and everything is okay."

He is calmer, and I place the line. He gets his fluids, and gets better. Apparently this 94 year old man's got a lot more living to do.