September 11, 2013

two stories: 9/2013

story 1*

After a month in the ICU, I worry I've become cynical.  Not because I don't believe in the power and might of modern medicine but because I worry that we use it too much instead of trying to help people cope with questions of happiness and mortality, quality and quantity of life.  Since my month has started, several patients have died in the ICU, all of them incredibly sick and all of the stories incredibly sad.  It's often a burden to carry the knowledge I've worked so hard to obtain about human physiology and pathology of different disease processes because it's often so much more obvious to me (and to the rest of the medical team) than to the patient's family that the patient - their husband, daughter, wife, brother - is not going to get better.

But this week I'm more optimistic.  I've been talking a lot with the partner of one of my patients, let's call the patient Tom and the partner Pat.  A few days ago (when I'm writing this, not when I'm actually publishing it) Pat was incredibly overwhelmed with grief.  Tom had been intubated for over a week and didn't appear to be getting any better.  Pat was plagued by the big questions that arise whenever a loved one is incapacitated and decisions have to be made by loved ones, including "is this what he would have wanted?"  Tom had come in directly from an ambulance after a motorcycle accident, had fractured his pelvis, arms, and legs, and had suffered multiple abdominal injuries requiring the placement of a feeding tube to give his intestines some time to heal.  He had also been intubated with an endotracheal tube and put on a breathing machine.  Tom had been through multiple surgeries at this point, had been given so much fluid to try to keep his blood pressure high enough to perfuse his brain and other organs that his skin was stretched and puffy.  His bruises that formed after the accident were turning every shade from blue to yellow and gave his skin a patchy appearance.  I talked to Pat most days and updated him about how we were caring for Tom and answered his questions about next steps.  But yesterday, Pat took me aside and just said to me, look.  I just want to know if you think he's going to get better, because I have to tell you, I'm getting discouraged.  Every day it looks like he is in more  pain, is more bloated, and getting worse.  And I totally got it.  Tom DID look horrible in lots of ways - the tubes, the lines, the sedation, the bloating, I tried to make myself see the picture that Pat was seeing so that I could fully understand.  But strangely, after four years of medical school and three months of intern year, everything I know now makes me look at Tom with great optimism; he's the kind of person who truly gets better in an ICU.  He had his reconstructive orthopedic (bone) surgery and it went really well.  The drains in his abdomen were taking care of a lot of the fluid.  His kidney tests looked great.   All of the cultures we had taken showed that he didn't have any infections.  Yes, he was sedated and using the tube to breath, but that wasn't because he necessarily couldn't breathe without it, it's that we we still determining if it could be removed, and were therefore sedating him so that he wasn't (appropriately) agitated by having a tube down his throat.  So I went through all of that - or most of it - with Pat and said, I know it doesn't look like it to you, but Tom really is getting better.  And Pat believed me, and it gave him hope.  I left for home that day thinking that it's these moments when I feel the most privileged, helpful, and just so proud of how hard I have worked to gain this knowledge and the skills to be able to explain them to help people cope.

story 2.

A few weekends ago, on a unique day off together, my husband-of-the-future and I biked to a farmers market in town.  We bought tomatoes, cheese, garlic, and iced coffee, wandered around a bit more checking out all the stalls, and then decided to bike home.  Our bike home took us on a bike path along a busy city street.  We were talking about what we were going to make for dinner when all of a sudden a motorcycle swerved into the intersection just as a taxi cap decided it would try to make the last second of a yellow light and the two collided in a loud crash.  Without pausing for one moment, both Chris and I biked right up to the accident, threw our bikes on the ground and went to the side of the motorcycle rider to assess him.  I'm sure if we had been a movie, the screen would have zoomed in on our minds scanning the scene for dangers, looking at the man to see if he was moving, breathing and if there was blood.  You would have seen us click through the steps of out-of-hospital resuscitation including CPR and rescue breathing.

And there may have been a flashback to another bike ride, in another time, when I didn't know what to do, didn't know how to be responsible for someone being injured, and instead of jumping into action, I froze.

The man turned out to be just fine.  He probably broke his ankle, but was otherwise completely injury free, just angry with the taxi driver.  During our assessment, other people had called 911, so by the time we were helping him move to the side of the curb, a fire truck was already arriving on the scene.   All in all, we didn't do much, but the fact that neither of us paused to think we didn't have the knowledge or the skills, but knew confidently that we did, was an amazing feeling in which to revel afterward.

*like all my stories about patients and my work, many details have been changed to protect the patient's and hospital's confidentiality, but the meaning is all true.  

No comments:

Post a Comment