Christmas Creep

It seems that every year, Christmas seems to sneak earlier and earlier. We lament (at least publicly; perhaps privately we cheer) the fact that decorations go up right after Halloween, sales occur hours after Thanksgiving dinner, and Christmas jingles flood the radio stations. Well, the operating room equivalent of that just happened. A surgeon walks in, plugs his phone into the sound system, and Christmas carols start playing. Although I've heard strange songs in the OR (Gregorian chants anyone?), this is one of the more unusual. At least it'll only last the month.

Thanksgiving

I am thankful for what I have, imperfect as it may be. I am slowly learning this harsh lesson, that nothing in life is perfect. Family, friends, work, marriage, self; they all have rough ends that need to be smoothed. The perfectionist in me wants to get everything just right, but I'm trying to change my perspective to viewing everything as the cliched journey rather than the destination. I accept the mistakes I make, the faults I have, the flawed expectations I have come to idealize. I learn to appreciate that which I have, which is more than I deserve, and which is more than many people ever get in their life. I am thankful for being loved, for those who care for me, for a job that gives me such tremendous satisfaction, for personal activities filled with creativity and joy. I am also thankful for those life lessons I am learning, for those nudges that guide me to becoming a better person.

November and December

I've noticed in several hospitals that the operating rooms get particularly busy in November and December. We have been operating at capacity, running nearly all rooms all day. Although I haven't looked at the data, the hypothesis is that many people want to squeeze in those elective surgeries before the year's end and their deductible resets. In addition, if one has to recover from surgery, it might as well be during the holidays. Perhaps surgeons are trying to make a little more money before the end of the year. I've always found these phenomena interesting: why deliveries happen more on weekdays than weekends, why pediatric surgeries happen more during summer breaks, and why November and December push our hospital capacity to the limits. Time feels like an artificial thing we've created, and medicine - whether rightly or wrongly - gets swayed by such external influences.

Medicine and Miracles

Medicine and miracles don't often mix. I think most doctors would tell patients we don't believe in miracles. How many times have I been in the critical care unit, holding the hands of a family member at the bedside of a dying patient? All their organs are failing; it is only a matter of time. I break the news as best I can, indicating that to the best of my medical knowledge, the patient will not survive. The family acknowledges what I am saying, but then tells me that they believe in miracles. They want to keep going in hopes that a miracle will happen. Every time I've had one of these situations, we wait hours, days, even weeks, and no miracle happens.

Yet sometimes, rarely, we find ourselves wondering whether we are experiencing a miracle. During my week in the intensive care unit, I admitted a patient who had a witnessed cardiac arrest. She came into the hospital with nausea, chest pain, and diaphoresis. While the emergency department was putting her on the monitor, she said she wasn't feeling so great, and on the EKG, they saw her flip from sinus rhythm into ventricular fibrillation. She lost consciousness, and the emergency department started chest compressions and defibrillated her heart. No matter what they did, however, they could not get her heart to stay in a perfusing rhythm. She got multiple rounds of epinephrine, lidocaine, amiodarone, atropine. She ended up being shocked over twenty times. She had compressions for over an hour. When I arrived, the floor was littered with empty syringes, open code trays, discarded equipment. But just as we were about to call it, that is, to say that there was nothing we could do to salvage this cardiac arrest, she regained a pulse and a normal rhythm. I quickly rushed her up to the intensive care unit, unsure of what the outcome would be.

We were most worried about injury to the brain. Without the heart pumping appropriately during cardiac arrest, the brain is entirely reliant on the quality of chest compressions. Many survivors of cardiac arrest have residual neurologic symptoms. Some never wake up. The best intervention immediately after resuscitating the patient is to cool him down because lowering the temperature reduces how much oxygen and energy the brain needs. It gives injured brain time to heal. We quickly began the cooling protocol anticipating that there would be significant neurologic impairment.

Imagine our surprise when she awoke, still intubated, and signaled that she wanted a pen and paper. As she wrote, we realized her brain was completely normal. In medical terms, she was neurologically intact, but what that meant was that she wrote to us about her symptoms, acknowledged us when we explained what happened, communicated with her family, and consented to her procedures. We quickly rushed her off to the cath lab and stented her heart; a heart attack had set everything off. Although her heart, kidneys, liver, and lungs suffered significant injuries during her cardiac arrest, within a few days, I managed to extubate her, stabilize her blood pressure, and transfer her out of the intensive care unit.

I have never seen someone recover like this after an hour of coding. It was truly unbelievable. All the physicians and nurses taking care of her were amazed. There is no doubt that good compressions saved this patient's life. Although it is true that witnessed cardiac arrests and ventricular fibrillation are both good prognostic factors to surviving cardiac arrest, this was still a miracle. I have never seen someone dead for an hour come back to life.

Cost of Medications

A couple months ago, the web had an outcry against a pharmaceutical company that raised the price of an antiparasitic drug outrageously. A start-up acquired rights to this old drug and immediately increased the cost by over 50 times. The whole thing felt quite ridiculous, and yet so believable. To those of us who've been in medicine for a while, this is not a new occurrence; I've seen half a dozen drugs increase in price when another company acquired rights to an old medication. I find it appalling.

The problem is that not everyone's interests are aligned. A company will try to maximize financial gain at the expense of patients. Their responsibility is to their shareholders or angel investors or employees. This may be acceptable in other markets, but when someone tries to take principles gleaned from tech companies or entrepreneurial startups and applies it to established medical systems, he might be biting off more than he can chew. We have all learned to put up with the cost of innovation; each time a new chemotherapeutic or hepatitis drug is released, there is some clamor about the cost, but we aren't trying to shame the company. Here, though, a company is capitalizing on an existing treatment, and that, I think, is crossing the line. I am not against trying to shake up a system - indeed, that's how we root out inefficiencies. But it seems morally indefensible to acquire an antimicrobial and then raise its prices prohibitively. Even if insurance companies will cough up the money for it, ultimately, it's contributing to the black hole of health care costs.

In health care, I believe companies must draw some lines on what is morally permissible. Health care workers are on the patient's side. We do what we think is best for them. We cannot allow the other factors - pharmaceutical companies, insurance companies - badger us into forgetting who we serve.

Failure of Advanced Directives

An elderly gentleman with many comorbidities including advanced heart failure is sent from his nursing home to the emergency department for shortness of breath. He is intubated in the ER and sent to the ICU. Another older gentleman with metastatic cancer who was just discharged from the hospital presents again with shortness of breath and cough. He, too, requires intubation and then gets sent to the ICU.

In the next few days, I meet with family members of both patients. Both patients have, in fact, expressed to their children that they would not want heroic life saving interventions. They would not want to be machine dependent. They might not have even wanted to be intubated had they been given the choice. In one case, the patient arrived from the nursing home without any records; no one knew about his DNR order until his daughter arrived. In the second case, the patient had been discharged home from the hospital several days earlier and immediately filled out an advanced directive to be DNR, but had not had the chance to notarize it.

In both cases I met patients with such severe comorbidities that their quality and length of life was limited. They told family members they would not want intensive care interventions if they became acutely and devastatingly ill. Yet somehow, whether by fault of system or no one's fault at all, they were intubated, on pressors, and in the ICU. In both cases, after lengthy family conversations, we transitioned the patients to comfort care. They spent the last few hours of their lives in peace, but the preceding few days were fraught with unneeded intensive medical care.

This is not an unusual occurrence. Why does it happen? How can we have such a technologically and medically advanced society and yet not get someone's wishes about their end of life right? Part of it is the fragmentation of data; a nursing home or primary care doctor or kitchen magnet contains the necessary information, but it's not passed on where it's needed. An emergency medicine physician, in absence of better information, errs on the side of doing more. It takes days for family members to convene and agree that the right course of action is to let go. All in all, we are talking about a lot of unneeded suffering and medical waste.

This is a problem we must solve. It is not fair to patients - and one day, it will happen to us - to not have final wishes respected. Even an intervention as simple as a bracelet might avert unnecessary harm and cost. There's a lot of worry that unlike an allergy bracelet, a DNR bracelet might dissuade health professionals from taking care of a patient. But I argue that if we go around sticking tubes in people's throats, IVs in their necks, and electrical paddles on their chests against their will, we're not caring for them at all.

Prayers

It is easy to forget our fragility: the fragility of human nature, the fragility of compassion, the fragility of civilization, the fragility of human life. We float through our everyday lives with such buoyancy, never really examining what we have and what we could lose. We can lose a lot. We have a lot of skin in the game. Strangers across the world tug at our emotions. Images of suffering, chaos cry out to us. Stories make us tear up. Emotions burst from the floodgates: disbelief, astonishment, fear, concern, anger, pity. We are fragile creatures, and we need to help each other, support each other, unite hand-in-hand. So much of our time is concerned with ourselves, with the small things, the frugal. Today is not that day. Today is a day where what we can give, what we can write, what we can support matters. We strengthen those connections we've made across continents, across generations. There are no strangers to humanity, and I hope that today, we let our humanity shine bright. No whisper is left unheard.

Image shown under Creative Commons Attribution Share-Alike License, from Wikipedia.

Names

I recently participated in a writing workshop and wrote a quick piece on names. Names are such fascinating things. We have little control over our names, and at some point in life, most of us wish we had a different name. They represent our identity, carry our heritage, connect us to family. The ten minute writing prompt was to write about our name. A few other physicians in the group suggested I post this.

My name changes each day. Every time I meet someone new, I struggle with what to call myself. If the patient is young and looks frightened, then I grasp his hand warmly and call myself Craig. If she looks skeptical or her lips are pursed or if she has more than two allergies, then it is a firm handshake and Dr. Chen. If the patient has been through World War II, or any war really, then it's back to my first name. They want to give me a title, to give me authority, but they command too much awe in my eyes. They've seen and weathered so much it feels disingenuous to establish a rank and hierarchy around them. If the child is old enough that I might ask what he wants to be when he grows up, I call myself Dr. Craig.

My name feels different rolling off different tongues. A nurse calls me doctor, and I insist on Craig. A surgeon calls me Anesthesia and I insist on Doctor. A ninety year old nursing home patient who has broken her hip, sensorium clouded by pain and confusion, calls me by the name of her late husband. I grasp her hand gently and don't say a thing.

Book Review: The Life-Changing Magic of Tidying Up

Many anesthesiologists are obsessive-compulsive. We get territorial over our workspace; we have our syringes aligned in a certain order, our drips plugged into the central line a particular way, and our clutter minimized. There's good reason for it; when a crisis happens, we want to know exactly where our emergency medications are, how many blood products were given, which IVs go where. I almost have a ritual in setting up my room, organizing it as the case is underway, and cleaning up at the end. And it's been life-saving, allowing me to maintain control under stress and pressure.

Perhaps this is why I so thoroughly enjoyed Marie Kondo's The Life-Changing Magic of Tidying Up. Filed away in perhaps the most boring section of the library, this book lays out a method to simplifying, cleaning, and organizing one's life. She's very particular in her demands, insisting on a certain attitude, conviction, method, and order to tidying one's possessions. And somehow, with this, she has created an international bestseller. I know a few people who have used her method, and they all swear by it. The goal is to surround oneself only with possessions one loves.

It's a very short book and an easy read. I think it's probably appealing both to the obsessively clean and the hopelessly messy. Even if you don't follow through with the whole process, it's somewhat enlightening in showing what a clean and organized life could be and how to get there. I really enjoyed reading it.

Image shown under Fair Use, from npr.org.

Culture and Medicine

Along the same vein as the last post, culture has strange influences and tendrils in medicine. We learn in medical school to respect different cultures, to understand why some may be reluctant to trust physicians while others want paternalistic physician-driven decision making. We try to be culturally sensitive, adjusting our approach to patients in a way that honors their perspective and values. These politically-correct statements sound obvious and easy but the practice is not so straightforward.

My last call night on labor and delivery, I met several patients of a particular ethnic background. In each case, when the nurse called me to discuss an epidural, I met a husband that completely dominated the conversation. When I asked the laboring patient something, the husband would interject with the answer. When I tried to obtain consent for the procedure, the husband would want to give it. As I explained what she might feel with the epidural placement, he reinterpreted my words and fed it back to her. It was as if she didn't speak English - but she did. He acted as an interpreter even though there was no language barrier.

It was a bizarre and jarring experience. Coming from a Western culture that tries to empower women, I was taken aback. How could it be that these women had no voice? I tried to engage them directly, but they shied away. They wanted their husbands to broker the interaction with the physician. I was torn. To try to foist everything on the woman seems to be forcing my point of view on her. But to allow the husband to be the sole spokesperson seems to perpetuate this feeling of discounting the patient. I was surprised how much I struggled with this one. In the end, I wanted to give each patient at least several opportunities to speak up and express her wishes and desires. If it was clear they wanted their husbands to speak for them, then I felt more comfortable with this strange patient-doctor relationship.

Denial

A 60 year old woman suffers a massive stroke and is admitted to the intensive care unit. Her course follows a similar one to many patients with this degree of injury; it gets worse before it gets better. Initially, she is able to speak, even if her speech is garbled and difficult to understand. But over the next few days, despite interventions, her brain begins to swell. Her mental state declines to the point where she needs to be intubated to help her breathe.

Over the next two weeks, her family struggles to understand her illness. Her recovery is minimal at best. I cannot remove the breathing tube because she has periods of apnea - where she stops breathing - and has no reflexes to protect her airway. Her eyes open to voice, but she doesn't follow commands. Her stroke is devastating. The recovery for such an injury takes months. We start recommending a tracheostomy and feeding gastrostomy, surgeries that will aid her recovery.

Each day, I speak to the sister and daughter. They see small changes and think they are big changes. They remember when she first came in and could speak, and don't understand why she cannot do so now. They expect recovery within days.

The denial is fascinating and frustrating. They can explain that both I and the neurologist believe she will take months to improve and that she needs the tracheostomy and gastrostomy. They can repeat back everything I say. Yet immediately after they do so, they say, "But I disagree. I think she will get better soon. I think she's made huge improvements compared to yesterday. I thank you for the medical opinion, but I simply don't believe it."

I am sure other specialties or professions are trained to handle these conversations, but I felt woefully unprepared. How do you pass along information to help someone make an informed decision when they simply decline to believe it? What tools or strategies exist to help someone move beyond denial? I tried to engage them in many different ways; our physical therapists had them see how much assistance she needed, I printed out resources in their language, I asked for a "cultural ambassador" to see them. Yet all I could do was give them more time. Not all challenges in the critical care unit are medical in nature.

Image of intracerebral hemorrhage shown under Creative Commons Attribution Share-Alike License.

2101

Oops! Usually I like to note a post when it falls on an even hundred. After all, this only happens two or three times a year. But it's been unnaturally busy. I wonder a little if busy is simply the new normal. It's not just being a doctor; so many of my friends outside of medicine also have lives that move so fast, hobbies that soak up free time, projects they commit to. Is this a phenomenon of our generation and time? Or is it simply the way things have always been, and I've been too oblivious to notice?

Sometimes, I wish I could find some measure of tranquility, some calm where I can breathe. There is so much I should reflect on. I try to, in this blog. There are patients and families I want to think about. Reactions that I want to examine. Desires and hopes I want to pursue. Doubts I need to clarify. Experiences I want to write. Medical knowledge I'd like to acquire.

I have a friend who meditates each weekend, for hours at a time. He spends an entire afternoon simply in nature, focusing, relaxing, observing, listening, seeing. Every weekend, he takes a day where he doesn't talk to anyone. He simply exists. I admire him so much for that.

I worry sometimes that this world has too much stuff, too much excitement, too much going on. I have totally bought into it. But I wonder what it would feel like if we could slow everything done, just for a little bit. These are some of the meandering thoughts I have as I finish my week in the critical care unit.