October 31, 2011

You just stop stopping it


When asked how you restart the heart after stopping it temporarily to put it on bypass, the perfusionist said to me:  "It's zen-like, really, you just stop stopping it"

Thursday around noon I scrubbed into my first Cardio case - a CABG (coronary artery bypass graft) surgery on a 74 year old woman who we'll call Elizabeth.  The procedure is done by taking a blood vessel from somewhere else in the body (in this case, the saphenous vein in the leg), disconnecting it from its normal place and reconnecting it to the heart to bypass a clogged coronary artery (artery that supplies your heart).  It's a pretty awesome procedure, but it's also done often enough that the expectations when you have one is that you'll be in the hospital for 4-5 days then go home and have to take it easy for a while during which time you feel so much better because your heart is working well again.

Needless to say, if that was the way this surgery went, I probably wouldn't need to blog about it.  I wrote a five page journal entry of everything that happened and my reactions to it, but I'll spare you most of that and just tell you what I'm still thinking about a few days later.

The surgery started out fine and routine, certainly not light-hearted, but pleasant.  Then slowly but surely everything started to go wrong; we couldn't keep her blood pressure high enough to adequately perfuse her organs, we couldn't get the wound on her leg from where we took the vein graft to stop bleeding, her right ventricle wasn't moving enough to pump blood through to her lungs, her skin was too thin to put stitches in to keep her chest closed.

20 hours and two additional surgeries later, she was left with an open chest where her heart had been attached to an external pump called an LVAD that was pumping blood around her right heart to give it a rest, a ventilator on her face attached to oxygen to make her lungs breathe, a line in her jugular vein, in her femoral artery, in both her antecubital fossas (inner elbows), her legs were stitched together along the whole middle side, like the seam of pants except her skin, she was bruised and swollen from the poking and the fluid and blood we had given her to try to keep blood flowing to all of her organs.

I went home at 4am, exhausted, wondering if she would make it through the night.  The next day I was in the operating room with a bariatric surgeon from 7am until I got a break at 3pm, so as soon as I got out of the OR I went to check on Elizabeth.  She was in the cardiac intensive care unit in the same state but even more bloated and with even more wires connected to her.

The surgeon was just coming by to talk to her family again and invited me to come to that discussion, so I went with him and heard Elizabeth's two sons and their two wives (who happened to be sisters, oh Maine) tell the surgeon that their mother would never have wanted to live like this.  Before deciding to have the surgery, she had decided her code status would be "Do Not Resuscitate" specifically to avoid this situation.  However, the surgeon did not want to accept that they would stop trying and just kept repeating, "we've done almost everything, but there are still a few things we can try; her left ventricle looks great; it's not likely but there's a small chance she will recover in some way; I can't say definitely that she won't have at least some turnaround"


I wanted to scream at him: they're saying that's not good enough - that some turnaround or a small chance that she will recover in some way is not enough of a reason to put her through this suffering.  They're saying they are ready to stop all this intervention.  But he kept pushing it: we can give her more blood, we can run some more tests, we could maybe do another surgery.  To Elizabeth's family's credit, they cried and lamented but they were clear - she would not want this.

When talking about it with another one of my attending from the trauma surgery service later that day, he described this behavior of surgeons: when they don't seem like they are listening and they just want to keep pushing even though it's time to stop, as Tunnel Vision.  He said, and you want them to have tunnel vision sometimes because it takes such focus to take a vein out of your leg and sew it to your heart and have you walk out of the hospital a few days later able to breathe and move again.  But this same focus sometimes makes it hard to see the person as a whole person, as a whole life, instead of just the organ they're working on.  This attending and I also talked about how to have conversations with families where you give them information that their family member is dying - how it should be straightforward, as objective as possible, laying out the options as clearly as possible, and how you should mostly be listening.  The biggest thing, he said, is that it never gets easy - even when you've done it thousands of times, it's always hard to tell someone that someone they love is dying.  And it should be.

October 24, 2011

the matrix


In my world right now this makes so much sense:


"So [given your extensive training and how hard you work] in your heart of hearts - why do you not quite feel like [you know everything]?

The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about."

- Atul Gawande 

October 13, 2011

getting stuck

today I was first assist on a below-the-knee amputation on an older man with diabetes.  It's a pretty brutal operation - as in, they actually use an actual bone saw, a very large knife and it's less possible than I thought it would be to precisely cut off the muscle in someone's leg.
But somehow I do have the stomach for surgery -  so even though at moments it seemed like a halloween trick gone awry,  I was able to focus on how fascinating it was to identify and technically interesting it was to  isolate the three major neurovascular bundles in the leg (sort of like tubes containing nerves and the blood vessels that supply them).



the attending sutured the muscle/fascia layer because that is the critical layer for holding the operation together
but then he let me suture half of the skin line.
I've just started feeling more confident in my suturing and yesterday I got to suture a lot, 
so I was feeling almost confident


until I stuck my own finger with the needle.


this is not an uncommon thing in medicine
in fact, the first thing that happened was that the scrub tech, the circulating nurse, and my attending all empathized with me and told me how many times they had been stuck

then they told me to take off my gloves and gown and go wash my hand with bleach
I was escorted from the OR to another building in the hospital to start the "needle stick protocol".
this consisted of me walking into the employee health center and being immediately ushered into a small room (they were expecting me because the OR had already called them), filling out a report about what happened, hearing what would happen from there on out:



1. The patient would be told that one of the health care workers in his surgery had been exposed to his blood, would he consent to be tested for HIV, HepC, and HepB please?  (he said yes) Would he please fill out a survey outlining his risk factors? (his wife did, he was still waking up from anesthesia)
2. I would fill out these incident reports.  One would be filed with employee health and one I would take to my supervisor.  Because I'm a med student and don't have a medical health record number, I would also have to create one of those.
3. I would have to have five tubes of blood drawn from the lab downstairs, now.
4. the nurse on call tonight would call me back with the results of the patient's STAT HIV test.
5. they would call me tomorrow with the results of his other tests and by Monday with the results of my tests
6. if I had any questions, I could call them.  If the tests were negative there was nothing else to do. If they were positive - well, there are more tests.
So I did.

I am really really lucky.
Less than two hours later, they called me with his previous lab results (all negative), and his risk factors ( blood transfusions in the hospital only - very unlikely to contain HepC or HIV), and later this afternoon called me with the results of his STAT HIV test - negative.
The nurse on the phone told me that I could breathe a big sigh of relief -
but that she'd still call me with all the rest of the test results.

Talking on the phone with the manfriend, he sounded almost more worried than I was, realizing for the first time that if we are both going to be doctors we are going to be at greater risk of contracting some pretty serious diseases.  And maybe more importantly, how will we organize our careers around this - will we try not treat people with more easily contractable incurable illnesses like HIV/AIDS? (hopefully we will treat them just the same as anyone else)  Will we wear more layers of gloves?  Will we be better about getting vaccines?  Get serum tests for transmissible diseases every year?  Or maybe just try hard not to think about it too much and carry on with what we've decided are our respective callings?

This article caught my eye because it explains some of the very scary things that can happen to med students, and yet is still very inspiring.  I'm reading Abraham Verghese's In My Own Country right now, which is about his own experience treating the first patients with HIV and it's making me think a lot about the balance between protecting yourself and providing good medical care.

~~~~~~~~~~~~~~~~~~~
"But we also agreed that what made the difference in life was not how well you succeeded;  it was how well you failed, how many times you picked yourself up
and put yourself back in the fray."
- Dr. Dietrich 
who contracted HepC from a needle stick as a third year medical student, 
see the article above

October 10, 2011

Home ?

Normally this is not really a photo blog.
But it's been a rough six months of moving around every 7 weeks 
(heyyy third year of medical school) 
that sometimes it feels like I'm always too far from everyone I love
so here's a photo blog reminder (for me, and maybe for all of you?) that my concept of Home has become an incredibly fluid concept that has less to do with location 
and more to do with the people I'm with

(if you click on the photos, they should open bigger in another screen)

"Oh home, let me come home
home is whenever I'm with you
oh home, let me go home
home is when I am me and you are you"
- Edward Sharpe and the Magnetic Zeros

because they are the best - my best friends came to visit me in Maine
and yes, that's the ocean behind us
(Maine)


getting ready to run... at midnight, before we have to wake up at 4am
and I think we still needed to pack.
what is wrong with medical students?
(Florida)

a quick jaunt back to Vermont to run a half-marathon - no big deal
(Vermont)


 finally with my fam
(Massachusetts)

summer break!
(Massachusetts)



 PLP Charlie and I reunited and hiked to waterfalls
(Vermont)

Burlington Farmer's Market - what a beautiful scene.
(Vermont)

 Rachel came to visit me finally!!
(Vermont)

Finally in the same place as Krista!
at a country fair no less, how perfect!
(Maine)

 Visiting Grace at her new beautiful apartment (we match)!
(Massachusetts)

Charlie and I demonstrate my favorite camera pose - the screaming eagle atop the summit!
(New Hampshire) 

Is there anything better than a kiss on a mountain?
(New Hampshire) 

We rolled out of the tent to watch the sunrise - 
what adorable sleepy men.
(New Hampshire)

the wind was crazy on the ridge
(New Hampshire)

 but it was beautiful - where else do you see colors like this, I ask you?
(New Hampshire)

which way did we hike?
(New Hampshire) 


(New Hampshire)









there's a few missing, so stay tuned, I might add some more!


October 6, 2011

Surgery at the End of Life

I've been thinking a lot this week about how strange it is that so many people are choosing such serious interventions for medical problems that are likely to not be their cause of death.  Don't get me wrong, we can do really amazing things with surgery and interventions now that save lots of lives and maybe even more importantly, improve the quality of life for so many people.  But it still seems like mostly, surgery should be an option of last resort.  Maybe this is more striking because I'm seeing all the patients in the ICU and in the hospital after surgery and recovery can be such a brutal process that it seems like, especially at an older age, surgery would be something you would want to avoid unless it was going to really make a difference in either the quality or quantity (or both) of years in your life.
Sometimes I wonder how much of it is just us not wanting to NOT be able to do something.  Like I said at the beginning of this surgery rotation, the really good surgeons are the ones who know when NOT to operate.

Check out this interesting article in the Times about how common surgery is at the end of life.

Dr. Jha provided a recent example from his hospital. A man had metastatic pancreatic cancer and was dying. A month earlier, he had been working and looked fine. “No one had talked to him about how close he was to death,” Dr. Jha said. “It’s the worst kind of conversation to have.” Instead, doctors did an endoscopy and a colonoscopy because the man had internal bleeding. Then they did abdominal surgery. “We did all of this because we were trying desperately to find something we could fix,” Dr. Jha said.
The man died of a complication from the surgery.
“The tragedy is what we should have done for him but didn’t,” Dr. Jha said. “We should have given him time to have the conversation he wanted to have with his family. You can’t do that when you are in pain from surgery, groggy from anesthesia. We should have controlled his pain. We should have controlled his nausea." Instead, Dr. Jha said, “we sent him to the O.R.”

October 5, 2011

Stay Hungry Stay Foolish


An extraordinary individual who changed the way we see the world and each other.

"your time is limited, so don't waste it living someone else's life. Don't be trapped by dogma - which is living with the results of other people's thinking.  Don't let the noise of others' opinions drown out your own inner voice.  And most important, have the courage to follow your heart and intuition.  They somehow already know what you truly want to become.  Everything else is secondary."


Gift from the Sea



an excerpt from a reading at a wedding my friend Rachel went to recently (and she so graciously sent to me because she knows me well and knew I would love it - thanks Rachel!!)



EXCERPT FROM "THE GIFT FROM THE SEA"
~ By Anne Morrow Lindbergh ~

When you love someone, you do not love them all the time, in exactly the same way, from moment to moment. It is an impossibility. It is even a lie to pretend to. And yet this is exactly what most of us demand. We have so little faith in the ebb and flow of life, of love, of relationships. We leap at the flow of the tide and resist in terror its ebb. We are afraid it will never return. We insist on permanency, on duration, on continuity; when the only continuity possible, in life as in love, is in growth, in fluidity - in freedom, in the sense that the dancers are free, barely touching as they pass, but partners in the same pattern.

The only real security is not in owning or possessing, not in demanding or expecting, not in hoping, even. Security in a relationship lies neither in looking back to what was in nostalgia, nor forward to what it might be in dread or anticipation, but living in the present relationship and accepting it as it is now. Relationships must be like islands, one must accept them for what they are here and now, within their limits - islands, surrounded and interrupted by the sea, and continually visited and abandoned by the tides.


Coaching


last night I was on call and around 4pm, a young guy came in with a gunshot wound to the knee.  Before I knew it, I was four hours into my first vascular surgery with the young guy on the table, both legs sliced open on the medial (inside) side).  The two surgeons I was working with were using a vein from one leg to take the place of the severed artery on the other leg, called "grafting" an artery for a bypass.  

I learned many things last night about vascular surgery and about vascular surgeons.  In their own words, these attendings said that vascular surgeons have to have the biggest egos, secondary only to cardio-thoracic surgeons (the men and women who operate on hearts and lungs).  They also are perfectionists - and need to be.  So I was surprised when near the end of the case around midnight, I was handed 0 nylon on a needle driver and forceps (big tweezer-like things that surgeons use to pick up skin to suture; suture = to put in stitches) and told to stitch up one of the groin incisions.  But I did.  The entire time, one of the attendings asked me questions about the physiology of the vascular system (for example, "what would I feel if I had accidentally attached this vein graft to the popliteal vein instead of the popliteal artery?"**)  while the other coached me on better technique for suturing.  Both of them were incredibly focused on details (appropriately for their profession) which is not typically my strength.  However, paying more attention to the details (where  your shoulders are facing, how far onto the needle driver you arrange the needle, locating each layer of fascia before creating a fasciotomy) ended up making such a huge difference.  
They say in surgery, if it feels like you're struggling to do something, you need to change something - because the best surgery is when everything is in line.  The change can be something as easy as switching the angle of your wrist or walking to the other side of the table or adjusting the light.  There are millions of things we can adjust but sometimes we think that they're just details.  But surgery has definitely taught me that the details truly matter.  Especially when learning, it's so important to learn the details before getting a gestalt.

On that same note, a few great friends sent me an article from the NewYorker by Atul Gawande, another one of my favorite doctor-writers: Atul Gawande, who writes about  how after their training is complete, surgeons (and maybe all doctors, maybe all professionals) operate without much supervision, without much continued assessment, and miss out on much improvement simply because no one is watching them and coaching them on how they can be better.  He relates this to professional athletes - who even though they are deemed the top of their fields, have other people who watch them as they cannot watch themselves, and help them improve.
Dr. Gawande also talks a lot about teaching styles and coaching teachers, another profession that is trained and then sent off into the world to manage on their own.

A great excerpt:
"Expertise, as the formula goes, requires going from unconscious incompetence to conscious incompetence to conscious competence and finally to unconscious competence. The coach provides the outside eyes and ears, and makes you aware of where you’re falling short. This is tricky. Human beings resist exposure and critique; our brains are well defended. So coaches use a variety of approaches—showing what other, respected colleagues do, for instance, or reviewing videos of the subject’s performance. The most common, however, is just conversation."
In the vascular surgery last night, it took so much of my brain power to both answer the questions and try to suture correctly that I don't think I even breathed the whole time, but afterward I felt like I had a greater understanding of what I need to learn to be a better doctor, moving more comfortably into "conscious incompetence".

**answer: no pulse because pulse is created by the resistance in arteries - and veins don't have very much resistance.  You would feel a thrill, which is a whooshing of blood past really quickly, instead.  If you listened to the graft, you would hear bruits, which is the sound of blood going by very quickly.


October 4, 2011

human touch

A ted talk by one of my favorite doctor-writers:


 ~~~~~~~~~~~~~~~~~~
 "wasn't that the definition of home - not where you are from, but where you are wanted?" 
-Abraham Verghese