Lesson: we can't fix everything

I watched a person die today. It was the first time I had ever been there when someone died. I was on call for medicine, and she came in by ambulance to the emergency department. She was very sick, and there were at least ten people working to help her for over two hours. But eventually her heart stopped pumping, and even though we tried all sorts of things to get it pumping again, nothing worked.

It was really sad. I know that as a doctor, I will see and know lots of people who die. But this person arrived alone, by ambulance, sick enough that she must have been very sick at home for at least a few days. When she died, we still hadn't managed to find any family. I was on call all night, so I left not long after - I'm not sure if any family was ever tracked down.

Part of me wishes that I could tell you her name, and a few more things about her - all things that I found out from her chart, after she died, because before that, I was too busy worrying about her blood pressure and her clotting factors and her heart. And I wish that I could make her more real, more of a real person than a thrashing body, gravely ill, and then an unconscious body, dying, then dead. Every person deserves a name, and a story, in the eyes of those who are with them when they die.

It's not like "ER" when someone is dying at the hospital. No one is yelling, and no one is crashing around grabbing supplies. No one mutters, "come on, come ON" under their breath as they do chest compressions. They work quickly, and efficiently. They keep their cool, and all the while they are quietly discussing what could be going wrong, and what IS going wrong, and what they can do to fix it. They consult each other - "phenylephrine or epi?" - and they calmly ask for more drugs, more supplies, more x-rays and more bloodwork. Today, they were all wearing masks on their faces, and in every set of eyes peering over a mask, I could see a gradually increasing level of concern. It grew until it was almost palpable, first worry and then a knowledge that whatever we did, the person was going to die. But we had to try, to do everything we could to keep that from happening. No one said it, but you could see it in every set of eyes.

I've been on call twice in the past three days. Wednesday night, my very first "real" call shift (that is, one that involves staying at the hospital overnight) was really good, even though I slept only 45 minutes between 6:30 a.m. on Wednesday and 2:30 p.m. on Thursday. I was busy, I saw lots of patients, and I learned more in that period than I had in the past two weeks. I was nervous when the shift started, but I figured things out, and I felt supported. It was kind of neat to be in the hospital late at night, looking at lab reports and x-rays and checking in on the patients unlucky enough to be stuck in the ER overnight. I worked with a good team, and my senior resident really made it a good night.

I was on call again last night, and I worked with a different team - I was basically a "loaner" because their own students were on call the night before. It was a lot quieter - I only saw one patient, then went to bed at 2:30. I got up at 7:45 this morning and left before noon. That's why I haven't written this week, even though I have been doing lots at the hospital and have been busy. I just haven't been home, and when I have been home, I've been sleeping.

I've learned a lot this week, but it seems that what I will remember is the woman who died this morning. I wish she could have known that she left an impression in the mind of a student, who will probably never forget.

Update

I realized tonight that I have been putting off posting on here because there's just so much to talk about, I don't know where to start. So I've decided to write one entry that covers everything!

1. Palliative Care and the goodness thereof
I did an elective in Palliative Care for the first two weeks of January. I loved it. It was the most fulfilling work that I've done so far. The days just flew by - I never found myself checking my watch or wondering when I could head home.

I did one week of inpatient medicine, where I worked with the hospital's palliative care team (a doc, a nurse practitioner, and a social worker) as a consultation service. That means that physicians would call us whenever they thought that a patient could benefit from our help. Our patients ranged from young to old, some very near death and some with a new diagnosis of a terminal disease. One relatively young man, very near death from a hereditary cancer that had already killed two close family members, really stuck in my mind. He was going home to die, and I spent a lot of time talking with his wife about how she would manage and what the future would likely hold. It was some of the most fulfilling "work" I've done since beginning medical school.

Palliative care, more than any other specialty that I've been exposed to, truly operates on the principle that each patient is an individual, with individual needs. For some, being at home when they die is the top priority - no matter how painful or difficult it might be. For others, going home is terrifying. They need the reassurance from the staff in the hospital or hospice, and not going home is a relief for them. Others don't care where they are or what we do to them, if we can just ease their pain. Some beg us to make their nausea stop so that they can spend a little time enjoying their families. Such simple things - organizing a homecare nurse or a hospice bed, or enough opioids, or the right anti-nauseant, or most of all, just listening - make an absolutely profound difference.

Like most medical professionals I suppose, I went into medicine to help people. Palliative care really made me feel like I was doing that.

Most people who are palliative care doctors do a residency in family medicine first (two years after graduating from medical school) and then do a one-year fellowship in palliative care. It's definitely on the "maybe" list for the future for me.

2. Anesthesia, part 2
Some people have what anesthesiologists euphemistically call "difficult airways." Generally that means they have no neck (or a very fat one), a short jaw, a big tongue, and a mouth that doesn't open very far. They're "difficult" because it's awfully hard to get a breathing tube down a throat like that.

For every surgical patient who is going to be put to sleep, we "assess the airway" while the patient is awake, by examing the things I've listed above, and then we make a call about whether the patient is anticipated to have a difficult airway. Unfortunately, we never really know if we're 100% correct in our assessment until we've put them to sleep with gas or intravenous drugs, and paralyzed their breathing muscles. Only they can we stick our scope into their throat and have a real look, without gagging them - and if you can't get a breathing tube in at that point, you need a backup plan in a hurry. (Just so none of you are swearing that you'll never ever have surgery again, you should know that there are some backup options here, the most drastic of which is a tracheotomy -- but they're not ideal, so in general it's best to avoid them.)

Anyhow. If someone is deemed on assessment to have a "potentially difficult airway," anesthesiologists get very skittish about putting that person to sleep without doing something to "protect the airway" first - because once we paralyze them, they won't be able to use conscious control to keep their airway open, and if it closes and we can't get a tube in, that is BAD NEWS.

During my second on-call shift of anesthesiology, a patient came in with a prosthetic joint that had become infected and needed to be removed immediately. The anesthesiologist described the patient to me, "a head like a soccer ball and a tongue bigger than my fist." The initial surgery had been done with the patient awake, under spinal anesthetic. However, when someone has an infection in their bloodstream, it's dangerous to do a spinal because the infection can get into the spinal fluid during the procedure. Therefore, this patient had to be put to sleep.

The only way to put a breathing tube into the airway of someone with a "difficult airway" is to do it while they are completely and totally awake. Imagine someone shoving a long cord (with a teeny tiny camera on the end) down your windpipe until they can see your vocal cords, and then stuffing a tube in. NOT FUN.

Even less fun when it takes about ten tries and you are choking on all the lidocaine spray that they're using to numb your throat (to keep you from gagging). It was absolutely AWFUL to watch, I can't imagine how much worse it must have been to experience. The doctors were doing everything in their power to minimize the unpleasantness, but the bottom line is that this is one of those times where you have to choose between comfort and safety -- and safety pretty much always wins that battle.

I'm still not in a hurry to see another awake intubation, though. *shudder* If you want to join in the shuddering, do a Google images search for "awake intubation."

3. Geriatrics
I'm currently doing a rotation in geriatric medicine, and loving every bit of it. There are five of us students working with two doctors, and it's wonderful. They do so much teaching, and they're wonderful role models.

I'm really enjoying the patient population, too. I think it, again, has to do with the idea that a very little does a lot for these people - holding a demented patient's hand, changing one drug order just a teeny bit so that the person isn't confused anymore, listening to their stories of World War Two - each is very meaningful to the patient and therefore very rewarding for me.

Not much more to say about that, really -- I'm having fun, and sadly it's only a two-week rotation. Next Monday I start Internal Medicine for six weeks. Don't plan on seeing a lot of me on here until the beginning of April!

4. The Wedding
Last but most definitely not least, the wedding planning is well underway. I had this naive idea that we would bask in being engaged for a few weeks or even a few months, and then slowly start looking into a few planning tasks. Ha. Turns out that you have to book churches and halls MONTHS in advance, and although we aren't getting married for 15 1/2 months, we are apparently already pushing our luck in terms of finding places that are available! It's madness!

We are considering sites both in my hometown and in the city where we currently live. At the moment, it looks like my hometown is going to win out, because things are more than twice as expensive in the city. (We're talking $65 vs. $25 per plate for the dinner.)

Finding an actual venue has been challenging to say the least. It's starting to sound like Goldilocks: this one is too far from the church, that one is on the second floor and lacks an elevator (a problem for our grandparents), another isn't large enough, another is just plain ugly. We may have found a place that will suit, though, so we're heading to my parents' house this coming weekend to check it out. Cross your fingers!

And once that's done, we only have to book a church and decide on attendants and find a dress and a tux and make invitations and think of some decorations and .....yeah. It's not going to be a boring year, at least!

On the topic of all that stuff, I can't BELIEVE the crap that people waste money on for a wedding! Stupid little giftey things that no one ever uses, elaborate gift baskets for their guests hotel rooms (yes, really, this is apparently a trend at the moment), and on and on. I remember the wedding of a family friend, when I was a little girl. The bride was being completely unreasonable about all the things that she just HAD to have for her wedding, but her father (a good friend of my dad's) was doing his very best to cater to her whims and make her day perfect. The breaking point came the day before the wedding, when she broke down in tears because she absolutely had to have one of those huge feather pens to sign the registry with. In fuschia, to match the bridesmaid's dresses. Her father exploded. But in the end, she got the pen. It was just a perfect example of how over-the-top weddings can get.

I'm glad the the Boy and I are both pretty down-to-earth about this stuff. We want a nice hall, yes, but it doesn't have to be palatial. Just comfortable and functional - and a bonus if it looks pretty nice so we don't have to decorate. I'm hoping to buy a used dress here. We'll probably drive to and from the church in my Mom's minivan. If we have centrepieces at all, they'll be something along the lines of a few floating candles in a bowl of water, or a couple of tea lights. We're going to make the invitations ourselves. I'm not even sure that I want to have flowers -- I'm allergic to them, and it seems kind of ridiculous to surround myself with things that make me sick on my wedding day. Not to mention the stupidly ridiculous environmental impact of the cut flower industry.

So yeah. At the moment, we're managing to keep it relatively simple. Hopefully it will stay that way!

Excitement!

We got engaged last Tuesday! Hooray!

The Boy and I went ring shopping together a few weeks ago, and after checking pretty much every store in town (some of them twice) and nearly driving The Boy (who hates shopping) totally bonkers, we found the perfect ring. Or rather, we ordered it, since it didn't actually exist.

The store was supposed to call The Boy's cellphone to tell him when it was ready so there would be at least a bit of a surprise for me, but they called while we were both home. After he got off the phone, I asked him who the caller was. "No one...." he said," but I might have to go out for a few minutes tonight." Big grin. I knew right away, and we were both so excited that we could hardly eat our supper before he went tearing out the door.

He was back in less than an hour. He swept me up in a big hug and asked me to marry him. Of course I said yes, so he made me look away while he put the ring on my finger:


The centre stone is an alexandrite. It's a pretty rare stone, originally discovered in Russia (The Boy studies Russian & eastern European history, so it's very appropriate), and the coolest part is that it changes colour. No, not like a mood ring! It goes from this beautiful emerald green stone in fluorescent light to a mauvey-bluey-grey in incandescent light, to reddish-purple in halogen light. In "mixed" light, it's almost black, with tiny flecks of different colours. I love it!

So, in May of 2007, I will become a "Dr." and a "Mrs." in just a few short weeks! Yowza!!!