Another one of those cases where being wrong rocks.
Yesterday afternoon, I overheard the doctor who had showed me the man with the Nec Fasc talking.
Apparently he was still alive (as of yesterday)and had actually regained his sight (he was blind prior to yesterday).
This may be the uplift before he dies, but it was not predicted, so maybe it means he will live. Maybe he didn't have true Nec Fasc and so the antibiotics we gave him actually worked.
All in all, a much more uplifting Thanksgiving story than yesterday's.
I guess nothing is ever certain, even when we are sure it is.
Thursday, November 27, 2008
Tuesday, November 25, 2008
Necrotizing Fasciitis
I saw a man with necrotizing fasciitis today.* This is a medical student's dream; the grand hoo haw of infectious diseases. Nec Fasc is not something that you come across every day. It's the joy of being a med student that every practicing doctor wants to show you this crazy thing they just found. They haven't seen anything like it in all their years of practicing, and there you are, lucky enough to be a student and the receptical of all things educational. Our job is to be enthralled, inquisitive, and to validate their excitement. We reassure them that this is fascinating, we confirm that this is important, and perhaps our learning injects some hope into what might otherwise be merely a tragic incident; a sad waste. But that might be vanity speaking.
So back to this man I saw today. I got chills tonight, a momentary tear in my eye when I thought about what I had actually seen. It was not just necrotizing fasciitis. It was not just an infection superimposed on an already feeble, ill man. It was this man's death that I saw. The way that his life will end laid out on his body like tarot cards predicting the future. By the time he was diagnosed, 8 hours after admission, the flesh-eating bacteria had attacked too much of his already crippled body. Down one leg, up his back, weaving it's way down his other leg. Like a wave in slow motion, yet so fast, too fast for his body, for our medicine. There was nothing to be done except treat him for pain, treat him with antibiotics for palliative care, and help him die. And that's what grabbed me tonight. I saw this man for, at the most, 5 minutes, but he made an impact on me and not just because I had never seen necrotizing fasciitis before. He's the first person I have had contact with in the hospital who I know is going to die in the next several hours. And what's more, I know what he will die from. In my brief time in the guts of the clinical world, I have met many patients who I know are not long for this world. I know that we are merely postponing their death, but I do not know which one of their 10 problems will finally claim them. So even though we know they will die soon, we are ignorant about what they will die from, and the patient and the doctor(s) are gifted the freedom of continuing on in the charade, blissfully naive to the ending. Seeing this patient was like watching Hamlet after having already seen it. There is nothing to do but simply wait for the ending that you know by heart. You want to run up and console Ophelia before she drowns herself. You want to pull the poisoned glass from Gertrude's lips before she drinks. You want to reconcile Hamlet and Laertes before they stab each other. But you can't, because the show must go on (or so they say), and the ending always comes, and it always comes in the same way.
And so I know that tonight, at 10:45, the infection has now completely consumed both of his legs. It has moved onto his upper body. I am almost certain that he has finally developed sepsis and possibly fallen into unconsciousness. It is quite likely that, at this hour, roughly 24 hours after coming to the emergency room, he has succumbed to the ultimate, irreversible outcome of such tissue destruction.
*Necortizing fasciitis is one of those things that really scares me - both from a doctoring stand point and from a patient stand point. In other words, it's something I'm worried I'm going to miss in a patient and something I'm petrified that I am going to acquire. It's also something that fascinates me. I get the same chills up my spine, the same obsession/revulsion feeling about it as I do about deadly snakes and sororities.
So back to this man I saw today. I got chills tonight, a momentary tear in my eye when I thought about what I had actually seen. It was not just necrotizing fasciitis. It was not just an infection superimposed on an already feeble, ill man. It was this man's death that I saw. The way that his life will end laid out on his body like tarot cards predicting the future. By the time he was diagnosed, 8 hours after admission, the flesh-eating bacteria had attacked too much of his already crippled body. Down one leg, up his back, weaving it's way down his other leg. Like a wave in slow motion, yet so fast, too fast for his body, for our medicine. There was nothing to be done except treat him for pain, treat him with antibiotics for palliative care, and help him die. And that's what grabbed me tonight. I saw this man for, at the most, 5 minutes, but he made an impact on me and not just because I had never seen necrotizing fasciitis before. He's the first person I have had contact with in the hospital who I know is going to die in the next several hours. And what's more, I know what he will die from. In my brief time in the guts of the clinical world, I have met many patients who I know are not long for this world. I know that we are merely postponing their death, but I do not know which one of their 10 problems will finally claim them. So even though we know they will die soon, we are ignorant about what they will die from, and the patient and the doctor(s) are gifted the freedom of continuing on in the charade, blissfully naive to the ending. Seeing this patient was like watching Hamlet after having already seen it. There is nothing to do but simply wait for the ending that you know by heart. You want to run up and console Ophelia before she drowns herself. You want to pull the poisoned glass from Gertrude's lips before she drinks. You want to reconcile Hamlet and Laertes before they stab each other. But you can't, because the show must go on (or so they say), and the ending always comes, and it always comes in the same way.
And so I know that tonight, at 10:45, the infection has now completely consumed both of his legs. It has moved onto his upper body. I am almost certain that he has finally developed sepsis and possibly fallen into unconsciousness. It is quite likely that, at this hour, roughly 24 hours after coming to the emergency room, he has succumbed to the ultimate, irreversible outcome of such tissue destruction.
*Necortizing fasciitis is one of those things that really scares me - both from a doctoring stand point and from a patient stand point. In other words, it's something I'm worried I'm going to miss in a patient and something I'm petrified that I am going to acquire. It's also something that fascinates me. I get the same chills up my spine, the same obsession/revulsion feeling about it as I do about deadly snakes and sororities.
Thursday, November 20, 2008
Alaska
This week, I saw a man in his 70's. He was wearing a thick flannel shirt, suspenders, and a trucker's hat. First question out of his mouth was "Who did you vote for? I voted for McCain." He's a retired bear hunting guide and taxidermist, but he still likes to guide for 30 day scientific expeditions through the Yukon, in the winter (yes folks, I did say he is 70). He also swears that fried chicken gizzards are just about the most delicious thing he's ever had.
Amazing.
Amazing.
Tuesday, November 11, 2008
I Love Tuesdays
One week later and I am still in shock. Like everyone else who blogs, I feel the need to put something down to mark such an historic, nation changing, nation shaping event and I figure that within 1 week, it still counts as current. I sent a text message to pretty much everyone in my phone (except for my die hard conservative friends). Below are all of the texts I received about the election over a 30 hr period, including the responses to my text. I heard back from people I hadn’t talked to in years, highlighting for me how enormous the collective sense of relief, freedom, and change was. My text was sent at 19:15, it is italicized
(And a side note: Tuesday is apparently going to be the most superior day of the week this year. .last week was the end of stupid-people-in-charge era, and today it’s dumping in Alaska. . .did I mention I’m back in AK these days.? . happy like a clam).
5:48: I’m at the polls right now-very exciting.
18:04 Looking good
19:15 Congrats! Woo! This is the best day in eight years.
19:17: Yay!
20:21: Owwwwwwww!
20:26: !!!!!!!!!!!!!!!!!!:)!!!!!!!!!!!!!!!
20:29: Amazing night! We can be prove americans again!
20:34: Maybe 30 years. Halle-flippin-lujah!
20:34: Absolutely!
20:38: Indeed it is.
20:39: I finally love america :) When can we get together?
20:40: Drinking and cheering
20:40: Historical moment my friends! Obama!
20:41: Fuck yay
20:42: Yes yes. ** says he has been depressed for 8 years. Just ichatted with – Log what a speech
20:45: Fuck yeah!! 221 years in the making.
20:45: Cap hill we’re all cbheering and crying and just f*ing ecstatic
20:45: Yes congrats to us all. It’s a great new day in this country.
20:47: No kidding!!!! It’s fucking AWESOME! Awesome speech too
20:48: Fucking amazing
20:49: Yay! Coming to the comet tomorrow?
20:49: Wooohoo! I have chills! That speech was incredible!
20:50: Indeed
20:50: Totally! So excited!
20:52: Hell yeah
20:53: People at literally dancing in the streets here in NYC.
20:56: oh hells yes. We’re in DC right now… total mayhem… like effin carnival… it’s beautiful… love.
20:57: Indeed! Bravo! Hurray! Watershed moment ;-D
20:57: woo hoo is right. What a great feeling! I still have goosebumps from his speech too!
21:01: Epic! So proud. Miss you!
21:03: Fosho… How u been?
21:09: Yeah!!! Um, who is this?
21:11: Not sure who this is but I agree!
21:14: Oh nice to hear from you. And thank goodness we won! I cried.
21:14: Yeah! I feel so good the election is over and obama won
21:15: Yay!!!!!!!!!!!!!!
21:17: Ppl lighting fireworks in Berkeley streets
21:20: so youre alive
21:22: Let’s see what happens on prop 8 before we get too excited, but yes, I am happy so far!
21:24: Gregoire!!!!!!! Obama!!!! Happiest moment of my life :-D
F Yeah America!
21:39: We did it! Democracy worked. We are a better nation today. I’m so damn excited
22:28: Why? What happened?
Wednesday, November 8, 2008
3:40: Yipeeeee!
6:01: Amen to that!
11:33: Who the hell is this
11:34: Hey my phone got messed up, who’s number is this?
11:37: Aw Jessie I miss you and I still cannot contain my happiness today. I wish we could celebrate together!
(And a side note: Tuesday is apparently going to be the most superior day of the week this year. .last week was the end of stupid-people-in-charge era, and today it’s dumping in Alaska. . .did I mention I’m back in AK these days.? . happy like a clam).
5:48: I’m at the polls right now-very exciting.
18:04 Looking good
19:15 Congrats! Woo! This is the best day in eight years.
19:17: Yay!
20:21: Owwwwwwww!
20:26: !!!!!!!!!!!!!!!!!!:)!!!!!!!!!!!!!!!
20:29: Amazing night! We can be prove americans again!
20:34: Maybe 30 years. Halle-flippin-lujah!
20:34: Absolutely!
20:38: Indeed it is.
20:39: I finally love america :) When can we get together?
20:40: Drinking and cheering
20:40: Historical moment my friends! Obama!
20:41: Fuck yay
20:42: Yes yes. ** says he has been depressed for 8 years. Just ichatted with – Log what a speech
20:45: Fuck yeah!! 221 years in the making.
20:45: Cap hill we’re all cbheering and crying and just f*ing ecstatic
20:45: Yes congrats to us all. It’s a great new day in this country.
20:47: No kidding!!!! It’s fucking AWESOME! Awesome speech too
20:48: Fucking amazing
20:49: Yay! Coming to the comet tomorrow?
20:49: Wooohoo! I have chills! That speech was incredible!
20:50: Indeed
20:50: Totally! So excited!
20:52: Hell yeah
20:53: People at literally dancing in the streets here in NYC.
20:56: oh hells yes. We’re in DC right now… total mayhem… like effin carnival… it’s beautiful… love.
20:57: Indeed! Bravo! Hurray! Watershed moment ;-D
20:57: woo hoo is right. What a great feeling! I still have goosebumps from his speech too!
21:01: Epic! So proud. Miss you!
21:03: Fosho… How u been?
21:09: Yeah!!! Um, who is this?
21:11: Not sure who this is but I agree!
21:14: Oh nice to hear from you. And thank goodness we won! I cried.
21:14: Yeah! I feel so good the election is over and obama won
21:15: Yay!!!!!!!!!!!!!!
21:17: Ppl lighting fireworks in Berkeley streets
21:20: so youre alive
21:22: Let’s see what happens on prop 8 before we get too excited, but yes, I am happy so far!
21:24: Gregoire!!!!!!! Obama!!!! Happiest moment of my life :-D
F Yeah America!
21:39: We did it! Democracy worked. We are a better nation today. I’m so damn excited
22:28: Why? What happened?
Wednesday, November 8, 2008
3:40: Yipeeeee!
6:01: Amen to that!
11:33: Who the hell is this
11:34: Hey my phone got messed up, who’s number is this?
11:37: Aw Jessie I miss you and I still cannot contain my happiness today. I wish we could celebrate together!
Sunday, November 2, 2008
Teaser
I am nearing the end of this whirlwind tour through academic medicine. I have had the impulse to blog, flashes of thoughts I wanted to put into written form, but my desire to reflect is weak compared to my imperative need for sleep. And so this page has remained silent for almost 6 weeks. Which is funny, because I feel brim full of epiphanies had and stories witnessed. So as I wind down my time here and transition back into the slower world of winter in Alaska, I am hoping that my memory will hold and I will have time to sort through the jumble of emotions and thoughts brought on by my last 6 weeks.
For now, this:
Frequently I look at those of us who are training to be doctors, and those of us who are residents, and those of us who are attendings and I think, dear god, we are just children play acting. There are young children, like myself, who mimic and there are older children, like the attendings, who decide which games we will play, but we are all nothing more than children in a big, scary, chaotic world. We have information gleaned from good and bad studies that we use to make decisions, we have the experience of the way similar situations have gone in the past, we have a stethoscope, we have MRIs, and we have blood tests, but these are weak defenses against the uncertainty that fills the spaces created by the heterogeneity of patients. There is, over our shoulders, a constant question of uncertainty. Sometimes it looms large, sometimes it squeaks small. The latter are days of success, I think. This uncertainty is not what I find disconcerting. It is expected, it is why medicine is referred to as an art rather than a science. It is why so many of us are drawn to the field.
What I find disconcerting are the ways that we try and manage the uncertainty. There is the ridiculous paperwork that tries to minimize unnecessary uncertainty. Perhaps our best response to it is the collaboration that is the foundation of doctoring. And our worst, the one that would keep me up at night if anything could keep me up at night these days, is our collective approach to each patient as a game, a puzzle to be solved, a mystery to explore, a lesson to be learned.
I think of the pre-code we were called to several days ago on a post-call morning. In front of us was an unconscious, large middle aged man. His pillow was red from the blood drooling from his mouth. He grunted to pain, when we pulled his eyelids open, we could watch his eyes rove back and forth in a rhythmic pattern. One side to the other, one side to the other. His vitals were stable, his blood gases normal, nothing to indicate what was going on. And the three, maybe four of us in white coats stood at the foot of the bed nonchalantly discussing his case.
R3: What do you think is going on?
Other R3: I have no idea. . . maybe a seizure?
R3: Yeah, that's a good guess. Probably is what it is. I mean, it doesn't look exactly like a seizure, but, what else could it be?
Other R3: Yeah, I mean, his vitals are stable, ABG was good n' normal, normal sugars. . a seizure could look like this, I think.
R3: So should we give him some ativan?
Other R3: Maybe. Did you call Neuro (to the intern)
Intern: Yes. Couldn't get ahold of them.
R3: Hmm. . I guess we could just give him the ativan, it's not going to hurt him, right?
Other R3: I don't think so. Seems like it's something to do.
Silence
Nurse: So do you want me to go get the ativan?
R3: Yes, I guess. . I mean. . I think so. Yeah, sure.
And so on. . eventually no ativan was given, and we all backed away from the patient as his primary care team arrived. He was still seizing, or doing whatever he was doing. I was struck by how we stood at his bedside, fascinated by what he was doing, without any urgency to fix it. I felt like we were children – our white coats fit too large, our stethoscopes looked awkward. Our feet shuffled. .how can we make this more fun again?
For now, this:
Frequently I look at those of us who are training to be doctors, and those of us who are residents, and those of us who are attendings and I think, dear god, we are just children play acting. There are young children, like myself, who mimic and there are older children, like the attendings, who decide which games we will play, but we are all nothing more than children in a big, scary, chaotic world. We have information gleaned from good and bad studies that we use to make decisions, we have the experience of the way similar situations have gone in the past, we have a stethoscope, we have MRIs, and we have blood tests, but these are weak defenses against the uncertainty that fills the spaces created by the heterogeneity of patients. There is, over our shoulders, a constant question of uncertainty. Sometimes it looms large, sometimes it squeaks small. The latter are days of success, I think. This uncertainty is not what I find disconcerting. It is expected, it is why medicine is referred to as an art rather than a science. It is why so many of us are drawn to the field.
What I find disconcerting are the ways that we try and manage the uncertainty. There is the ridiculous paperwork that tries to minimize unnecessary uncertainty. Perhaps our best response to it is the collaboration that is the foundation of doctoring. And our worst, the one that would keep me up at night if anything could keep me up at night these days, is our collective approach to each patient as a game, a puzzle to be solved, a mystery to explore, a lesson to be learned.
I think of the pre-code we were called to several days ago on a post-call morning. In front of us was an unconscious, large middle aged man. His pillow was red from the blood drooling from his mouth. He grunted to pain, when we pulled his eyelids open, we could watch his eyes rove back and forth in a rhythmic pattern. One side to the other, one side to the other. His vitals were stable, his blood gases normal, nothing to indicate what was going on. And the three, maybe four of us in white coats stood at the foot of the bed nonchalantly discussing his case.
R3: What do you think is going on?
Other R3: I have no idea. . . maybe a seizure?
R3: Yeah, that's a good guess. Probably is what it is. I mean, it doesn't look exactly like a seizure, but, what else could it be?
Other R3: Yeah, I mean, his vitals are stable, ABG was good n' normal, normal sugars. . a seizure could look like this, I think.
R3: So should we give him some ativan?
Other R3: Maybe. Did you call Neuro (to the intern)
Intern: Yes. Couldn't get ahold of them.
R3: Hmm. . I guess we could just give him the ativan, it's not going to hurt him, right?
Other R3: I don't think so. Seems like it's something to do.
Silence
Nurse: So do you want me to go get the ativan?
R3: Yes, I guess. . I mean. . I think so. Yeah, sure.
And so on. . eventually no ativan was given, and we all backed away from the patient as his primary care team arrived. He was still seizing, or doing whatever he was doing. I was struck by how we stood at his bedside, fascinated by what he was doing, without any urgency to fix it. I felt like we were children – our white coats fit too large, our stethoscopes looked awkward. Our feet shuffled. .how can we make this more fun again?
Subscribe to:
Posts (Atom)
Posts
