Losing Hope

This is not an uncommon ICU story. A patient with cirrhosis has been on the transplant list for years. He develops progressive hepatic failure, and the sequelae of liver disease start manifesting. He becomes confused, develops varices, builds up fluid in his abdomen, starts bruising and bleeding. The blood pressure starts dwindling and the kidneys start failing. He needs a new liver or he will die.

About 6000 liver transplants are performed in the U.S. every year, but there is still a big organ shortage; approximately 1800 people on the transplant list will die because they could not get an organ.

This patient presents with encephalopathy, pancytopenia, and hypotension. I admit him to the ICU, hydrate him, start him on norepinephrine, begin lactulose, and hang antibiotics. His MELD score, which determines liver transplant priority, is quite high and I talk to his hepatologist; both of us agree he needs to get to a transplant center. Transferring him earlier is probably safer because things will only get worse. I contact nearby tertiary hospitals and tell his family this may be his best chance.

Then the labs come back. Unfortunately, he is septic with E. coli growing in his blood. In my head, in my experience, I know this is it. He won't survive a systemic infection, and no one is going to give him a liver until he clears it. He doesn't have time. I've already started a third pressor, and I know intubation is just around the corner.

I am still learning to deliver bad news. It's one of the hardest things I do. How do you walk into the conference room knowing that hope is all that is sustaining the family but that the hope is ephemeral? How does the pendulum swing from one extreme where you are scrambling to transfer a patient to a transplant center to the other where you believe the best thing is comfort care? Is that my goal? If I am certain he will not survive to transplant, should I recommend stopping aggressive treatments and heroic measures? I don't want to intubate him. I don't want to dialyze him. I don't want him to suffer without a prospect of getting better.

Hope is tenacious. Even when something is doomed, we ache with hope. Even the most rational of us find ourselves in situations where we pray, wish, bargain, yearn. Ultimately, after hours of discussion with the family, we ended up transitioning to comfort care; he was never intubated and could communicate until the very end. No one would say the situation was good, but I have seen so many worse deaths and I'm glad he was pain-free, talking to his wife, and surrounded by his children in his final moments.

Opiates

The epidemic of prescription opiate overdoses is a really complex issue. It's gotten a lot of press in the popular media especially as President Obama declared this a national crisis. But I'm afraid this is a much more nuanced issue than most people realize. There is no doubt that the number of emergency visits and accidental deaths from prescription opiates has skyrocketed. We are seeing less heroin, methamphetamines, and cocaine, and a lot more oxycodone and morphine. But the solution is not clear to me.

Recent guidelines strongly recommend avoiding opiate prescriptions outside of cancer pain and palliative care. In particular, there are recommendations to avoid long acting or slow release medications. Alternative pain medications including drugs normally considered for neuropathy, inflammation, and epilepsy are highly recommended. Indeed, I've read several recent research studies supporting de-escalation of opiates outside of cancer and the end-of-life.

These guidelines are quite reasonable, but for me, they highlight the difficulty in treating chronic pain. In anesthesia residency, we spend only a little time in the chronic pain clinic, but it is still more than family practitioners get. The few months I worked with pain patients taught me that treating pain is a highly specialized practice requiring advanced training. Of course, there are hardly enough pain specialists out there to care for the epidemic of chronic pain and its resultant epidemic of prescription opiates. But it does shine a light on the fact that complex patients should be referred to a pain practice.

I've met drug-seekers and malingerers, and I've also met patients with real chronic pain. In treating chronic pain, I believe (and have been taught) that long acting or slow release medications are crucial. They provide a foundation of effective pain relief in the same way that long acting insulin provides a background dose. Short acting medications help with spikes of pain in the same way that short acting insulin is given for meals or snacks. Avoiding long acting opiates can create big swings in pain management where the patient gets behind and then takes too much to catch up; it can disrupt sleep and impair function.

I definitely agree with multimodal management of pain, using non-opiate alternatives such as antiepileptic, antinflammatory, and neuropathic drugs. But in seeing patients on these complex regimens, I realize the risks of polypharmacy. It can be challenging for patients to keep track of their different medications or physicians to manage their side effects and interactions. When I read the geriatric literature, all of it suggests paring down on medications. How do we balance these conflicting recommendations?

I guess in the end, I chose not to be a pain specialist for a reason. But when I see the lay media, medical journals, and CDC recommendations on how to curb prescription drug abuse, I question how simple they make it sound. Like any other epidemic, tackling this is not easy. I hope that pain management physicians will step up to engage the public, educate physicians, and research ways of reducing overdoses and accidental deaths.

Gap

Sorry for the big unexpected gap in blogs. The end of June is always an interesting time. In academic hospitals around the country, senior residents are graduating and new interns are orienting. Soon, new teams of residents, bright-eyed and bushy-tailed, will start on the wards. Clinic patient panels will be handed off to the next practitioner. My wife starts a new job. My brother begins an orthopedics internship. Even at the community hospital where I work, where there are no residents, we feel the change. The summer is when new hires, fresh out of residency or fellowship, begin their first jobs. We see new faces among the hospitalists, surgeons, consultants, and even the nurses and technicians. With this, I hope there comes a since of renewal, of emergence, of new goals and resolutions. Oddly enough, my calendar has always been organized this way; I count my first work anniversary soon. I reflect on what I have done this past year and what I hope to accomplish in the year coming up. Starting in private practice has been challenging in its own ways. I learned how to be flexible, how to adapt to changing circumstances, how to walk into call prepared for anything. My anesthetic techniques changed to accommodate the speed and efficiency of private practice. I honed my skills and my judgment, integrated myself into a system, got to know a wonderful cohort of partners, surgeons, nurses, and staff. I tackled problems, surgeries, and intensive care patients that I had never seen before. I started acquainting myself with billing. It was a really busy year; many of my mentors told me the first year of practice is one of the hardest, and I am glad I made it.

Personality

One of the most fascinating aspects of neurology for me is the idea that parts of our identity can be altered by illness. It's easy to imagine that diseases can change our memory or our sensory perception or our balance. But I've always been so curious of the idea that illness can affect parts of ourselves that seem so intrinsic and fixed. When I first read Oliver Sacks' The Man Who Mistook His Wife for a Hat, I was most drawn to the stories where personality changes with illness. There are bizarre diseases that can make patients hyper-religious. In my psychology course, I loved hearing about Phineas Gage who had an iron rod pierce his brain's left frontal lobe in a railroad construction accident.

He survived the accident, but his personality changed dramatically. How can an injury change who we are?

That last time I was in the intensive care unit, I saw terribly sad example of this. A young woman presents with several weeks of subacute altered mental status. Her sense of smell and taste change. She becomes less interactive, more withdrawn. Eventually, she has a seizure at home and is brought into the emergency department. She is intubated for recurrent seizures, and her head imaging shows enhancement of the temporal lobes. A tentative diagnosis of HSV encephalitis is made, and she is started on acyclovir. However, during this hospitalization, she starts exhibiting extreme behaviors including suicidal behaviors that her family says she's never had. What a terrible and strange disease that can make someone suicidal. I wonder how this happens on the level of the neurons and neural networks.

Image is in the public domain; from Wikipedia.

Beauty in Everyday Life

I've been pretty worn down lately: long days at work, stressful cases, insomnia, fractured relationships, family tension, difficulty motivating myself, overwhelming emotions. I anesthetize a patient for a bronchoscopy and biopsy of a lung mass. Under the microscope, it looks like small cell lung cancer. Her imaging shows disease outside the lungs; when I realize she likely has metastatic small cell lung cancer, I am greatly saddened that she may only have months left to live. The day before, in an orthopedic surgery with unexpected blood loss, I am splashed in the face with blood and irrigation. Glasses covered in blood, I pause the slightest bit but then continue to transfuse products and place an arterial line. A couple days later, a surgeon requests a central line in the middle of a surgery and I have to place it in a terribly un-ergonomic position; my shoulders still ache. On my way home, I realize I have been remiss in calling back friends, working on my projects, tidying up the household.

On weeks like this, I remind myself to slow down. I try to curate more art in my life. I've been filling the house with music when I get home. I've been changing the wall art. I make time to go to the SFMOMA, which just recently reopened. I cook. I write a poem or two. I cherish deep conversations with those I love. I take a walking meditation. I find beauty in the books I read.

How do we cope with those intense, confusing, and exhausting emotions in our personal and professional lives? How do we decompress from stress, avoid burnout, and find beauty in each day? How do we go from a work that is technical and scientific to an everyday world which is imperfect yet filled with art, music, literature, dance, and beauty?

Changes in Family Structure

Over time, the composition of family has changed. We moved from living in extended families with multiple generations under the same roof to having smaller nuclear families. Our families are more spread out geographically; it's no longer common for an entire clan to live all in one neighborhood. And now the Millennials are changing things even more. The so-called Generation Y are marrying later, having children later, and delaying rites of passage. It's been described as the Peter Pan effect; these Millennials are living with their parents longer and pursuing longer routes of education. How will this change health care in a couple decades?

I've been pondering this as I've seen a small uptick in the number of people undergoing surgeries unaccompanied by a family member or friend. Most of these procedures are small outpatient surgeries, but it's still surprising when I hear their plan after surgery is to take Uber or Lyft home. (That in itself, is a question - is it safe to discharge a patient from a hospital to a smartphone transportation service?).

But what happens when the Millennials get old? When we are hospitalized in the intensive care unit with a pneumonia or after cardiac bypass surgery or from a car accident, who will make our decisions? The vast majority of surrogate decision makers I see in the ICU now are spouses and children. But with the Millennials, we might start seeing other people take that role. Even those with children are having them later. If a sixty year old man has a stroke and would not want to live dependent on machines, would his thirty year old daughter be able to make that heartbreaking call? What about a twenty year old daughter? Those of us who are unmarried and have no children may depend on our siblings or other relatives more. What if we don't have any? Will we rely on our friends to make life-altering medical decisions? Will we be able to make those for our friends?

When we leave the hospital, who will help us with the recovery? If a third of us are unmarried and have no children, will we lean on those more-distant relatives? Friends? Neighbors? Childcare and elder care has changed a lot now that few households have multiple generations living under the same roof. Will new societal innovations change how we deal with illness in the setting of changing family structures?

Ramblings on Race, Culture, and the Doctrine of Separate Spheres

Race and ethnicity can be touchy subjects to write about. I don't want to make any generalizations, and yet, I've noticed very striking patterns in how culture affects the way people interact. In my experience, this has been most pronounced in labor and delivery.

I wrote a blog several months ago about a husband who dominated a conversation I was trying to have with the wife (the patient). This happens at a surprising frequency. For a specific ethnic group, communication seems to happen via the husband, almost like an interpreter. When I ask a question, the husband will repeat it to the patient. If the patient has a contraction, she will whisper it to her husband who will then communicate it to me. Although I respect this is how they communicate, it is strikingly different than what I am used to (or expect).

It makes me think of the doctrine of separate spheres. In early 19th century Europe (though the idea has been extant in Western thought for much longer), men dominated the public sphere; they were allowed to engage in politics, business, and interactions outside the household. Women, on the other hand, participated in the private sphere of domestic life, housekeeping, and childraising. It was improper for women to cross over to the public sphere; indeed, it would be indecent for a woman to be seen in public unaccompanied. These gender roles permeated the culture and thought of the time; it wasn't until the mid-20th century when feminist theorists began to refute this doctrine (ie., The Feminine Mystique).

This is what that interaction in labor and delivery feels like: some clash between the private sphere and the public sphere, and the husband traverses the gap. This hypothesis may be completely wrong; the ethnic group isn't a Western one, but it's a thought I have in the middle of the night on my eighth epidural. Other ethnic groups also have their own particularities. For example, one group of patients commonly asks their mother or sister to stay for the epidural rather than the husband. The sociology of pregnancy is a fascinating topic.