I think there is an unspoken expectation that people at the time of their death will have last words. Some final message they have been waiting to impart, whether it be words of reconciliation for long estranged relatives, or a simple goodbye to those they love. In this archetypal deathbed image, family members are gathered around the bed of the dying, who is clear, lucid, and distills a lifetime of experience into a few words of wisdom before sighing once, and passing on.

The sad reality is that most people never get a chance to say anything before they die, because they have long since lost the power of speech.

I recently sent a man home to die. A man who, a mere month ago, I had treated for a relatively straightforward pneumonia. Unfortunately, old age is insidious, and at a certain point, it can become quite hard for individuals to recover even from straightforward diseases. On his readmission, this elderly gentleman stated his pneumonia had resolved, but he still had fatigue. So we admitted him, and began working him up to locate other possible sources of the infection his labs indicated he still had.

And I spent the next 2 weeks watching him slowly but gradually decline from an interactive, lively, hard of hearing old gentleman breathing on his own to a nonverbal, nonambulating, shell of his former self, lying in bed on oxygen, while the family met with the palliative care team. A thorough inspection had revealed no infectious source, his cardiovascular status had gone from poor to practically nonexsitent, and finally I had the dubious responsibility of telling his family, "I'm sorry, there's nothing more we can do. Perhaps it's time you think about taking him home."

The family, while saddended by the news (understatement though THAT be) understood, and we discussed the options available before they decided they were in agreement with comfort measures only, a do not resucitate order, and bringing the patient home to die in a familiar setting.

I signed the discharge orders, knowing I would never see this patient again. I tried harder than I could say to recall when the last conversation I had with him was, reaching to find anything at all that could be construed as last words and not just my one sided questioning of daily symptoms to which he could only respond with nods. I came up with nothing.

So I sent the family home with last words of my own: Whatever your beliefs are, I sincerely hope that your loved one finds peace and happiness in accordance with them. Then I stepped over to the computer, clicked the order to discharge, and watched as they disappeared forever.

The numbers on the clock read 3:30. 30 minutes until I am protected from admissions, 90 minutes until I get to go home. I spend my time idly performing chart review for my research project, digging through months of notes to grab minor details for the statisticians. Suddenly the pager goes off.

"Oh no oh no oh monkeyfeathers!"

"Hi Dr J, we have a patient for you to admit, and this is a good one for the subintern, so have him do the H&P."

I inwardly cringe. The sub-intern on my team is a nice guy, but like all students cant help but slow me down when I was hoping to knock this out and be out by 5. Nonetheless, I agree, the sub-I and I briefly review the pts chart and down we go to visit him.

The pt is a 55 yr old gentleman with a past history of high blood pressure, high cholesterol, and recurrent urinary tract infections here with another urinary tract infection and some shortness of breath. I let the student take the lead in questioning while I scribe notes. After 10 minutes (my patience threshold when I am trying to go home) I subtly begin to help direct the students questions to the pertinent information.

The biggest concern with our gentleman is his low blood pressure. Someone who reports a history of high blood pressure coming in to the ED with 74/61 is worrisome. More so when that blood pressure barely corrects after 4 liters of fluid. To clarify, I want you to imagine you have just drunk 2 of those giant soda bottles.

Despite the fact that this man is sitting up and talking to me, that he appears relatively healthy, he is in septic shock. Lab tests revealed more disturbing values. A creatinine (kidney function measurement) of 5.4, where a normal level is 1.0 So on top of his sepsis, he had acute renal failure. Oh yeah and troponins were elevated as well (heart injury lab) meaning he had some demand ischemia (almost, but not quite heart attack) also likely due to his sepsis.

So it was off to the ICU with him. I called up the admitting fellow and informed him of our plan.

"Yeah that sounds fine, but drop a central line in him so we can give pressors and antibiotics"

No problem, except I had never done one of those before. Looked at my watch. 5:30pm. Duty Hours and my internal devil are telling me to sign it out and call it a night. But how in good conscience am I just supposed to walk away? Do I tell the family, sorry, residents have an 80 hour cap, some other doc will come in and jab a needle into a major vessel.

So I sighed once for my lost evening, and went to track down an attending to supervise me while I placed a central line. A central line is a large bore catheter placed in either the neck, chest, or groin. Most interns/residents tend to opt for the femoral option as it is 1)slightly easier to place a line and 2) does not carry the risk of puncturing the carotid artery or causing a pneumothorax among the more traditional complications of the procedure

I, however, am not most residents.

I explained all the risks of the procedure to the patient, and then the benefits and why I thought he needed this and should consent. I clearly managed to convey the appropriate authoritative and experienced image because rather than saying "YOU ARE GOING TO JAB A HUGE NEEDLE INTO MY JUGULAR VEIN? ARE YOU EFFING CRAZY?" instead he went with the more traditional-"whatever you think best doctor."

Perhaps he may not have had the same level of confidence if he knew this was going to be my first one ever. But hey, that's the price of going to a teaching hospital, right? The secret to success is sincerity-once you can fake that, you've got it made.

Gowned and gloved in sterile attire, I palpated the gap between the two heads of the sternocleidomastoid, finding that magic triangle, in which the ultrasound tech located the compressible vein. Then, after cleaning the site, and injecting lidocaine to numb away the sensation of having a rookie poke around in your jugular area, in I went!

I wish I could tell you I was insanely talented and got it on my first try. However it took about 3-4 times of advancing and retracting the needle, and finally moving more lateral away from my initial puncture wound before I finally saw the inrush of venous blood. I maintained my serious doctor face the whole time while my internal monologue was screaming "YOU HAVE A NEEDLE THE LENGTH OF YOUR HAND IN THIS MANS NECK, QUIT MUCKING ABOUT!" and successfully inserted the catheter with only a modicum of blood spilling onto my gloves, and no complaints of pain from the patient.

I had successfully inserted my first central catheter, with no complications, and in a more challenging location. I ordered a chest xray to check the placement, and sent him off to the ICU. The time was 8pm, 3 hours after I was supposed to be off, but totally worth the experience. Next time, I will be much less hesitant and once again, I will go for the throat!

Dr J

I am surprised at how much fun it is to have med students around, more confused than I am, making me feel like I'm a genius, or at least that I'm a doctor. Hey, after five months I know things! I know the abbreviations people use! I know what's probably serious and what's probably not! I know when to call a rapid response! I

I try and sit down and teach the med student when i can, even if its only for 5 minutes. I remember being a med student. I remember how awesome it was when the interns and residents helped me out like that, and it definetly influenced my decision to pick internal as a field. So I'm trying to be a good intern and help them feel not so lost. I'm actually starting to figure out what I'm doing and getting comfortable. It's probably some of each.

My one complaint would be that is is kind of hard to make friends in the program. Mostly because there is no communal downtime. Everyone is on a different rotation, in a different part of the hospital or even a different hospital, and we never actually have a chance to get to know each other. In med school you have classes, you have lunch, you have extracurricular activities.

Not to mention there isn't a lot of "not at work" time that people have in common and can make plans. My day off might not be your day off, my early night is probably your on-call night, you're on days and I'm on nights... so even if I wanted to make plans with someone, it's almost impossible. But bit by bit the five minute conversations add up. I just have to try harder to motivate people to go out, I suppose

Outside of medicine, I will be performing stand up comedy again in the next couple weeks at a relatively well know LA comedy club. Anyone in the area should swing by and check it out

While on my way to noon conference today one of the med students stopped me and asked me how I liked the program. I told him truthfully, I was very happy with it. Then he asked if there was anything I didnt like about my residency program.

And I had to stop and think about it. I remember not so long ago when I was in the exact same position on the interview trail, questioning every resident I could find about hidden flaws, what the program directors werent telling you. It was almost cute to be so interrogated.

So I wanted to give him an honest answer. I thought long and hard, and at the end of it, I honestly couldnt come up with anything. There are certainly things I dont think are perfect, but they are the same things I would be complaining about in any program. As things go I have it pretty good. No overnight call, a q6-7 call schedule on wards, great coworkers, attendings who are enthusiastic about teaching, a prompt and efficient ancillary staff, the list goes on. Nothing overtly bad or unpleasant really came to mind.

I told him so, and then I smiled to myself. It was nice to rrealize that I picked the right program for me.

After all, the man who is truly happy is the one who smiles when there is no one else around to see

Residency is hard work. There's a lot to keep track of, whether it is patient care issues, studying for licensing exams, or just wondering about my overall performance and what the other residents/interns think of me. Am I the intern that has the horrible notes? or the one who everyone is glad to have on their team? I know the medication i need to prescribe, but what is the proper dosage and why does everyone but me know it? WHY DOES THE PAGER KEEP GOING OFF?

So with the minute little stresses throughout the day, it's important to find ways to keep myself grounded in reality. Or at least my reality. So what helps me get through those stressful days?

 

--Taking the stairs from the 6th to 7th floor and pausing to look at the hollywood sign through the glass wall

--shouting "wheee" and throwing my hands up as i enter the steep highway ramp on my way home from work

--wandering the halls of the hospital humming whitesnake when nobody's looking (and journey when they are)

--checking off boxes on my to do list for patients

 

what helps keep YOU sane?