trolling the obituaries

trolling the obituaries.

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trolling the obituaries

There’s this really great coffee place about 4 blocks from my house. I go there most days when my schedule is light, and if I’m working a normal schedule, I am usually able to make it there at least once a week. The barista, Scott, is friendly and rather skilled at making my quad latte, and he knows me as a regular. As soon as I walk through the door he makes eye contact and mouths, “the usual?” to which I nod “yes” prompting him to quickly start making my drink, even if there’s a line. I feel like Norm. A table decked out with magazines and newspapers is located right next to the cash register so you can read while you wait. I’ve developed this ritual in the last several months in which I grab the paper and go directly to the obituary page. I think this is probably a fairly common practice among older people entrenched in a local community. While no spring chicken, I wouldn’t consider myself “older” and I’m not a pillar of local society, as I’ve only lived here 18 months. I take care of many of the people who end up on this page and my interest in reading their obituaries, while perhaps melancholy, helps me cope with the death that surrounds me in my work.

The Sunday paper is particularly full of data and I pour through the obituaries looking at names, ages, where they died, and if I’m lucky, a cause of death will be listed. There are few things more unsatisfying than reading the obituary of a 35 year-old man that doesn’t include the cause of death. But I digress…I recognized the name immediately as belonging to a patient I admitted to the ICU the previous month. Mr. H was transferred from another hospital for further care, which is common at our institution because of its extensive catchment area and the inability of smaller hospitals to care for complex, critically ill patients. Mr. H came to us for treatment of severe DKA, or diabetic ketoacidosis, a metabolic disorder that occurs in diabetics.

Mr. H wasn’t on insulin, but was supposed to be on medications to sensitize his body to the effects of insulin. Insulin is necessary for glucose metabolism, glucose being the body’s preferred fuel source. When there is an absence of or insensitivity to insulin, organs use alternative fuel to try and maintain function. This alternative fuel is fatty acids. It’s an ingenious solution, but doesn’t come without risks. Fatty acid metabolism results in the production of ketones and if allowed to continue for very long will result in the blood becoming acid-y. In this acid-y environment, proteins necessary for vital bodily processes cease to function and the balance of potassium, calcium, sodium and other electrolytes-which is vital to proper organ function-become increasingly deranged. At the same time, the person is peeing like crazy to try and rid the body of the extra glucose. If left untreated, severe dehydration ensues resulting in dangerously low blood pressure, decreased oxygen delivery to all organs and this, in conjunction with acid-y and electorlyte imbalanced blood, causes the person to fall into a coma. If this point is reached, the risk of death is extremely high. Mr. H was not in a coma, but his blood sugar was in the thousands, his blood pH was 6.9 (considered severely acidotic) and he was confused.

The day he was admitted, he was pulled over by police because of dangerous driving. In his late 70s, he continued to work as a truck driver. He was weaving from lane-to-lane in his 18-wheeler and police initially thought he was drunk. After evaluation at the ER it became evident that his slurred speech, confusion and strange behavior was not from alcohol intoxication. He was transferred to our ER and then to our ICU and that’s when I met him. Upon walking into the room, I was struck by Mr. H’s physical appearance: He was almost translucently pale, was grotesquely cachectic and was behaving erratically. He looked agitated and his glance darted frantically from place to place like someone who is high on methamphetamine. I asked him several questions and he began confabulating in the most comical and friendly way. He described in detail how he had driven to our ER from his daughter’s house in town and stated he came in to find some ball bearings. He commented that he liked my tattoos and that back in the 1960’s, his wife had a pair of glasses just like mine. He had no idea where he was or why and clearly needed close monitoring while (hopefully) recovering. Although he looked chronically ill at baseline, I was hopeful we could turn around his DKA quickly so he could get the hell out of the hospital before something really bad happened to him.

Treating DKA is usually pretty straightforward: Give a cocktail of insulin, lots of intravenous fluids, electrolytes and then…watch. Sometimes an acute illness can trigger DKA e.g. a heart attach or pneumonia, but more often than not it happens because the patient hasn’t been taking his medication correctly. Mr. H had a small area on his chest x-ray that seemed to implicate developing pneumonia as a possible contributor, though overall he appeared much less sick than most of our patients. Initially he responded well to treatment and quickly became more coherent, talking pleasantly and more logically with us about football and truck driving. Unfortunately, as often happens in the ICU, he started having trouble breathing after a couple of hours, required higher and higher amounts of oxygen and his blood pressure dropped dangerously low. After talking it over with his daughter over the phone, we placed him on a breathing machine. Maybe this could still turn around…

During the couple of weeks that followed, he collected one medical problem after the other: The first night he had a “mini heart attack” which could either have been the cause or effect of the DKA, who knows. It became apparent on hospital days 2 and 3 that his heart was damaged to the point of working at only 60% of its ideal capacity. This dominoed into kidney dysfunction, which prompted the need for dialysis on hospital day 5. On hospital day 8 he developed inflammation of the gall bladder, but because of his other issues wasn’t stable enough to go to surgery. In order to control infection by draining pus around the gall bladder, a drain was placed that went from inside his belly to a bag at the side of his bed. This was hospital day 9. Three days later he started having massive diarrhea probably, at least in part, related to the powerful antibiotics used to treat his pneumonia and gall bladder infection. And so it continued, each problem arising one after the other, like water spurting from a new hole in the bottom of a boat after a previous one has been plugged. The last night I took care of him we noticed he was having severe rectal bleeding. The nurse complained that the daytime team hadn’t had any frank discussions with Mr. H’s family about his progressive illness despite aggressive life support. On hospital day 14 he had a colonoscopy and an EGD, though no source of bleeding was identified.

With almost every organ failing, what was his chance of survival? If he did survive, what was the likelihood that he would live independently again? What would his quality of life be? At what point would the care we provided be considered ineffectual? And what about his wishes? If he could speak for himself, would he tell us to keep going or stop? None of these questions were asked or answered. But although he couldn’t communicate due to delirium, we had some clues about what he might say about what we were doing. An aversion to health care and to following physician recommendations was documented over a period of years. He went to the doctor only sporadically and when he did, he never followed recommendations or took the medications prescribed. Medical non-compliance isn’t a reason to refuse or limit care, however, such behavior can illustrate a person’s perspective on medical care; Mr. H’s medical biography suggested he was decidedly disinterested in being medicalized, even in the smallest way. In addition, his daughter, herself a hospice nurse, stated on numerous occasions throughout his stay that, “he doesn’t want to be kept alive on machines.”

Although common, this statement is frustratingly useless to help make decisions in the critical care setting for a variety of reasons. First, people change their minds, both when it is their own as well as their loved one’s life on the line. Of course people should be able to change their minds and it is understandable that one could wish one thing for oneself in the abstract only to change course completely when staring into the face of death. In addition, surrogate decision makers tend to believe that their loved ones’ ability to survive is higher than it actually is; and the sicker the patient is, the wider the gap between fantasy and reality. This also is understandable: It’s a natural human inclination to feel that oneself or one’s loved one is unique and can “beat the odds”; however, the “odds” are the “odds” for a reason, and they apply to us all, miracles not withstanding. Invasive interventions such as breathing machines, dialysis, CPR and the like are complex and the layperson often ascribes supernatural powers to and expects unrealistic outcomes from these interventions. If they do realize the inevitability of the outcome, families often experience critical care as a runaway train that is impossible to stop or feel overwhelmed with the responsibility of “pulling the plug”.

We physicians don’t really make these scenarios any easier. A physician would likely never ask a patient, “So, you have high blood pressure. Would you rather take a beta-blocker, an ACE-I or a diuretic?” The physician, unlike the patient, has the knowledge and experience to make this decision which is based on disease guidelines, other medical illnesses the patient has, as well as (possibly) considerations of cost. Though the physician will likely explain what the medication is and why it’s necessary, the physician doesn’t ask the patient to choose among a variety of options not only because the risk-benefit leans overwhelmingly toward benefit, but also because the patient can’t possibly make an informed decision. Not that patients are dumb, they just aren’t doctors, right? Certainly, a negotiation can and should be involved when side effects are experienced or goals are not achieved, but the doctor is making the diagnosis, formulating the treatment plan and writing the prescription. However, in the ICU somehow physicians encourage situations in which the tail ends up wagging the dog, for lack of a better idiom. For example, I witness daily interactions among physicians and patients/families that follow a typical course: The physician provides an incredibly complicated, jargon-laden explanation about illness(es), the myriad possible clinical scenarios and then dispassionately offers a confusing array of invasive and complex treatments. This would be akin to me taking my car to a mechanic, him explaining some elaborate and complicated engine issue, followed by his asking me which, among a variety of (what I would consider) dizzyingly complicated services I’d like performed on my car. I’m not a mechanic and don’t know the difference between a chassis and a transmission, so I need the mechanic to share his expertise, stereotypes of mechanics’ integrity not withstanding.

I’m not suggesting that things should go back to the old paternalistic “doctor-knows-best” way of many years past, but in my view offering interventions such as breathing machines, dialysis, and CPR as if they are menu items to be chosen a la carte is irresponsible. People rely on doctors to use our knowledge to inform and help them. When provided with a hypothetical clinical scenario, the overwhelming majority of physicians would not themselves want CPR, mechanical ventilation, feeding tubes and other such interventions, whereas the overwhelming majority of lay-people would want these interventions in this same hypothetical scenario. Am I the only person who thinks it’s strange that we as doctors would provide care to our patients that we wouldn’t want for ourselves? One way to bridge this gap, particularly with respect to potentially painful and oft-ineffectual interventions, is, rather than providing a menu of services from which to choose, to elicit the patient’s values and wishes as well as their expectations about living and dying. We can’t expect patients and families to have the knowledge that we ourselves must acquire over years of practice, not to mention the objectivity that is clearly absent when one is going through crisis. Physicians shirk the mentorship responsibility because it’s uncomfortable prognosticating regarding bad outcomes. No one wants to be the bad guy and it’s hard for us to accept that there isn’t another trick in the bag, that our smarts and procedural acumen have been exhausted. In the event the family does make the difficult decision to forgo further aggressive care, we often inadvertently allow them to suffer under the misconception that they are “pulling the plug”.

It can be different. We can support families by reframing the discussion about medical interventions as well as life and death. In situations where our training and experience tell us that further invasive care is prolonging death instead of supporting life, we can share this perspective. We can reassure family that they’re acting compassionately in their role as advocate, that we as the medical professionals are responsible for the medical decisions as informed by the patient’s wishes, and it is the illness, not the withholding of medical interventions, that is responsible for their loved one’s death. Perhaps more controversially, we can structure our institutions in such a way as to support physicians’ clinical decisions such that we aren’t put in the position of offering medical care that, our experience informs us, is overwhelmingly unlikely to produce the patient’s or family’s stated goal(s). There are always going to be situations where patients or families want more or different interventions than we think is appropriate, but the more we strive to learn about the patient as a whole person, the less likely this is, at least in my experience.

So, on this random Saturday I was getting my coffee and once again morbidly perusing the local obituaries. There it was, Mr. H’s obituary. It was short and unceremonious. I had a pretty heavy heart after reading it. Although confused, he was funny and congenial during the hours before being put on the breathing machine. I felt sad for his suffering, suffering I had had a hand in, although with the most altruistic intentions. Also, I met his daughter several times and she clearly had his best interests at heart and loved him very much. I felt sad for her loss and her grief, both of which I likely made worse by not leveling with her. Beyond the personal impact of his death, the fact that things could have been different is painful to consider. He could have, at least in the last days or week of his life, had a physically, emotionally and spiritually gentler death. Those who loved him could have had the chance to focus on his uniqueness rather than the tubes going into and out of his body. When Mr. H’s brain (delirium), heart (heart attack and resulting congestive heart failure), lungs (pneumonia and dependence on a respirator), liver (inflamed gall bladder and blood coagulation problems), and kidneys were all failing, I could have had a compassionately frank discussion with his family. I could have disclosed that Mr. H’s likelihood of survival was < 5%, if that. I could have explained that if he did survive, he would likely remain on the ventilator for the rest of his life (which would be short) and he would require 24-hour care. Being a fellow in training and also the night physician, I didn’t feel it was my place to speak these truths. Instead, I kept quiet and Mr. H continued to get intervention after intervention until finally his daughter realized what the medical team had known for some time, that her father was dying regardless of what we did to him.

Not that I’m a megalomaniac-I doubt that anything I could have said would have changed the course of his care. But had I doctored genuinely in addition to proficiently, I would have retained the ability to feel good about my human integrity, as well as my professional skills which I used to make technical decisions and performe procedures. Maybe next time…

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another day

I’m with a patient, ultrasounding her arm, actually. It’s a day on-call like any other day. I was asked by one of the hospital doctors to examine her in order to see if I could put in an arterial line. The patient needed such a catheter to measure her blood pressure because it couldn’t be measured in the usual way, with a sphygmomanometer. The reason this patient’s blood pressure couldn’t be measured the non-invasive way was because of widespread vessel hardening. She is a “vasculopath”, in other words, because of systemic sclerosis, a rheumatologic disorder characterized by diffuse organ scaring and calcium deposition, almost all of her arteries and veins were hard like an eggshell rather than flexible like rubber. Because the vessels aren’t pliable, the pressure surges that move through them with each beat of the heart can’t be accurately measured, and this measurement is what we recognize as blood pressure. One can imagine it would be difficult to insert a tiny needle into such a small and rigid structure. Even her giant, anaconda-like right arm arteriovenous fistula, a medically engineered artery-vein connection used for dialysis, was completely scarred and useless. She had been hospitalized repeatedly during the last year or so with various and sundry complications from the systemic sclerosis and it’s treatment. This was likely to be her last hospital stay, as there wasn’t much else we could do to prolong her short 54-year existence outside of a hospital.

I spend my days and not infrequently my nights evaluating patients for admission to our ICU, or otherwise help with procedures or suggestions for how to better treat difficulty breathing, low blood pressure, etc. The ICU is a unique place in that only the sickest patients are “allowed” admission, and doing such work is interesting, rewarding, but also heartbreaking. Because of progress in medical care, people are living longer and surviving illness that used to be almost uniformly fatal. However, as I’ve learned over the years, some things are worse than death. Despite this, I’m here to help both patients and colleagues, sometimes when it goes against my better judgement. This was the situation on this day.

I was asked by a colleague to place a catheter into this woman’s artery, a procedure that is painful and, in this case, wasn’t going to provide information that would help anyone make her better, prolong her life or make her more comfortable. Many people are likely surprised that we doctors provide such care, but it happens with relative regularity. So, on this slow Saturday evening I wandered up to her room with my ultrasound anticipating a somewhat less-than-straightforward procedure, searching my mind for any excuse to give to the requesting physician for why it couldn’t or shouldn’t be done.

She lay in her bed with a sign above it reading, “legally blind” which would be obvious to anyone who looked at her-both her eyes were red, inflamed and swollen and she had that “off in the distance” stare that many blind people possess. She was snuggled under her purple fleece blanket snoozing as I knocked on her door and then walked in.

“Hi Ms. B, my name is Dr. F. I’m here to take a look at your arm. The nurses weren’t able to get a blood pressure earlier and your primary doctor thought maybe a special catheter might be helpful.” She awoke pleasantly, unlike most of the people for which I care; usually my patients are either sedated to within an inch of their lives or so cranky that I wish they were.

“Oh, ok. They told me they couldn’t get my blood pressure, is that why you’re here?” she asked. “Yes, I’m not going to prick or poke you,” I offered, again hoping to convince the hospitalist that this could be avoided via non-invasive surveillance. “I’m just going to look at the vessels in your arm with my ultrasound; no pain! Just a little cold and slimy jelly,” I purred. “Ok, go for it!” she replied gamely.

Located to the left of her head was a touch pad sensor. With a turn of her head she could activate an alert with her left temple. This alert would trigger a chime at the nurses’ station so that they’d know she needed assistance. More often than not it was accidentally or inadvertently set off, either by her or a visitor (like me) and a voice would come over the intercom, “Ms. R, can I help you?” She would reply, “No, I’m ok, just getting’ comfortable.”

That’s how debilitated she was-she couldn’t even hold a remote control in order to push a button with a single finger. Despite this, she appeared as placid as someone napping on a park bench in the summer sun. I felt terrible disturbing her, but the job had to be done. I pulled her purple fleece down from around her neck to reveal her left arm which, like the rest of her body, was riddled with scars, sores, bruises and tight skin, the last of which is the hallmark of systemic sclerosis, the former three emblematic of her intimate association with inpatient medical care. I gently unsnapped her gown at the shoulder to expose her arm from shoulder to wrist. From her mere history it was evident that the usual artery used for such monitoring-the radial artery at the wrist-was not likely to be accessible. As an obstetrician does when she’s looking at the fetus in a pregnant woman’s belly, I slowly moved my ultrasound up and down the inside of her left arm searching for the round, pulsating sign of life.

I saw veins, and here and there, some TINY arteries as well as fat and muscle. But rather than being black, plump and pulsatile, the arteries looked like white, withered pieces of chalk that barely twitched, let alone pulsed, which indicated poor blood flow. No wonder she was on dialysis, was bed-bound due to bilateral lower extremity amputations, and had suffered four heart attacks. After several minutes of searching, I found a puny but palpable artery in the crook of her elbow. Although I probably wouldn’t be able to cannulate such a miniscule tube, my ability to feel the throbbing movement of blood indicated that her blood pressure was probably at least 80mmHg and she was likely perfusing her organs. Sigh. Salvation from performing this procedure was most certainly mine.

As an aside, my professional recommendations are not always heeded. Maybe it’s because it’s the middle of the night or because the primary physician is uncomfortable not DOING anything, or maybe it’s because I have colorful tattoos from my shoulders to my wrists, who knows. In this situation, as in many others, I recognized the need to prepare myself to perform a procedure even if I didn’t think it was necessary or even possible. So, I spent several more minutes investigating her arm for an appropriate target. Finally, up under her armpit, I found an artery primed for the poking. I watched while it pulsed and this in conjunction with her ongoing chattering, left me reassured. Probably desperate for human contact and conversation she talked non-stop about her hospital stay, her illness, and her daughter, among other things.

I clumsily soiled her blanket with jelly and apologetically wiped it down with a towel. “What a great bedspread, it’s so soft,” I offered feebly. “My daughter gave it to me, isn’t it wonderful? But my favorite is my elephant. It is so fluffy! She gave it to me for Christmas. So, you know her? She’s supposed to come visit tonight, I wonder where she is…She said she’d bring that elephant!” She spoke in a strangely childlike way. She was dependent on everyone for the smallest of tasks, so trusting and sweet and so content with simple things like stuffed elephants. “You’re never to old to appreciate something soft to cuddle with,” I mused honestly, contrasting in my mind the pleasure of a silky soft doll with the paper-like roughness of the towel I used to clean the jelly from her arm.

Just as I finished, the overhead emergency system chimed, “ANESTHESIA TO ER ROOM 1 STAT! ANESTHESIA TO ER ROOM 1 STAT”…then about 15-20 seconds later, “ANESTHESIA TO ER ROOM 1 STAT! ANESTHESIA TO ER ROOM 1 STAT!” My sickly but gentle companion, having herself been in-and-out of hospitals her entire life, commented good-naturedly, “That can’t be good. I’m glad it’s not me!” To which I replied, “Nope, it’s never good when you hear that,” silently thinking to myself, “Shit, whoever that patient is, he’s probably coming to me. I better get back downstairs.” I then left with the parting offering, “I’m all done, everything looks great, your blood pressure is fine. I don’t think we need to put any iv’s in now, but if we need to later, now I know where to go! Do you need anything?” Of course she answered “no,” as I’m sure she almost always did. She was undoubtedly one of those patients who, no matter how ill they are or how legitimate their needs, doesn’t want to be a bother.

I weaved my way through the halls, walking down to the ICU with my ultrasound-on-wheels in tow, like Luke Skywalker with R2-D2, and resumed my perch at a computer outside a patient’s room. Over the ensuing couple of hours we received no admissions and overall it was quiet. I was able to follow up on things for other patients and make sure they were tucked in for the night. “He’s oxygenating well,” and, “her blood pressure is too low,” or “she needs a transfusion,” floated through my mind as I reviewed labs, vital signs and Xray results. “HE needs to go to heaven,” I thought as I perused the chart of a particularly elderly, demented and prolongedly critically ill patient. I typed madly, entering orders for everything from blood cultures and antibiotics to instructions to a nurse to tie down a patients hands so he couldn’t pull out his endotracheal tube…Saving lives with every stroke of the key, I thought to myself. Just then a cry echoed from the other end of the unit.

You’d think that in my line of work I would be familiar with this kind of emotional outburst. It’s true that I often console families when I have to give bad news or inform of a death and though routine, it’s always sad. But most of the people I take care of are elderly or at least older, and are chronically ill. Furthermore, my patients’ ICU stays are almost always easily predicted, if not by themselves or their families, by us as the medical professionals. I would estimate that the overwhelming majority of my patients are at least 55-60 years old, have a chronic, devastating illness such as advanced cancer, heart failure, chronic lung disease or the like, and have been in and out of the hospital (and probably the ICU) multiple times in the preceding months. This latter group belong to a cohort we call “frequent flyers”. Although not terminal in the traditional sense, they have incurable, progressive but treatable diseases. These patients often spend more time in a hospital or ICU than they do at home in their last months of life. Despite the fact that studies consistently demonstrate that most people want to die at home, most people actually die in either an ICU or hospital bed. I can confirm this anecdotally and it makes death more prolonged, painful and traumatic than it would otherwise be. It’s not just the patient and the loved-ones who suffer, but medical professionals carry the burden of providing aggressive, death-prolonging (rather than life-sustaining) treatment. When our patients die after this kind of course, it is upsetting and their families weep, however, often times these deaths are also a relief for family and medical professionals alike.

The cry I heard as I typed away was not the cry of a child, sibling or even spouse of an elderly, infirm patient at the end of a prolonged illness. This was a guttural, pained, and desperate howl. It was startling and disturbing, and it made the hair on the back of my neck stand up. I recognized it instantly as the sorrowful sob for a dead young person. I immediately, if not morbidly, looked in the direction from which it was coming. The groaning was preternatural. It pierced my ears and burned like an electric shock all the way down to my fingers and toes. My resident and I looked helplessly at one another and then a sore, inflammation-like pain moved into my chest and throat. It took my breath away and my inclination was to either escape or make it stop.

As this sound echoed throughout the ICU, my resident told me the story behind the scream. A young man had been skiing with his friends and wife. Subsequent to skiing into a copse of trees he had suffered what seemed like an inconsequential fall and injury. Just after the fall he was coherent and seemed fine, though had significant chest and abdominal pain. His wife, who coincidentally is a resident at our hospital, responsibly called an ambulance. His vital signs were stable and there was no evidence of grave injury on physical examination, so he was transported to our hospital via a ground ambulance. Unfortunately, by the time he arrived at our ER he was comatose, his blood pressure was un-measurable and just as he was rolled into the ER he stopped breathing.

The overhead call “ANESTHESIA STAT TO ER 1!” I had heard while examining Ms. R’s arm was the desperate call for help intended to speed up this young man’s transit to the OR. According to my resident, himself a third year anesthesia resident who had gone down to the ER to see if he could help out, this patient had suffered a catastrophic injury that had initially gone undiagnosed. It only became apparent that something was alarmingly amiss when his blood pressure dropped, he became confused and his abdomen became increasingly distended in the minutes before arriving in the ER. The surgeons, anesthesiologists, and nurses worked quickly and frantically as this young man fought for, and subsequently lost his life, all the while business as usual in the ICU continued. Despite heroic attempts to save him, he bled to death and died on the operating table. He was then brought to our ICU and the wails we heard were coming from his wife who had just been told he had died.

“No, no, no, no, no, no..!…What am I going to do? What can I do?!? I don’t know what to do! This can’t be happening…please!?!? No, no, no, no, no…” and so it was repeated in a kind of loop, interspersed with moans, and exclamations of desperation, agony, disbelief, excruciating pain. I was strangely intrigued and at the same time horrified by this scene, and I couldn’t help but steal a glimpse of her lying in his hospital bed as she screamed and stroked her dead husband. I can only describe this experience as a combination of rubbernecking as one drives past an accident coupled with the instinct to bite or rub one’s tongue on a painful canker sore. At the same time, it was all I could do to block from my mind the image of my own beloved dead in that bed, myself in her position. How surreal it would be to see the love of one’s life lying there pale, motionless and dead, all the while remembering that just yesterday, all was well.

I felt physically nauseated and searched my mind desperately for something to do, but there was nothing any of us could do. As a physician, there always seems to be a solution to any given medical problem. All day, every day in the ICU is characterized by tasks: We interpret data, perform procedures and procure consultations. Death is typically not stealth. We can see it coming and in the meantime we do stuff to hold it at bay for another day, another week, another month. When it finally comes, it’s expected, and we think we know how to make it easier by again doing stuff: Injecting morphine, removing tubes, calling the chaplain. This was a decidedly different death and all of my skills, medical and interpersonal alike, were totally useless.

No one teaches us, not in medical school, not in residency, and, not in fellowship, how to deal with such a shocking scenario. I doubt if anyone could ever teach you how to best console a woman in this situation, but what about self care? When there is nothing to be done, where does that energy go? Certainly it’s unsettling, but maybe we can use such experiences to live better lives and be better doctors. On the other hand, some older, more “experienced” physicians will advise you to, “Brush it off. Dont’ be upset.” But if something so unnatural is not upsetting to your doctor, is that healthy? Furthermore, is that the kind of doctor one would want taking care of one’s husband, mother or child?

Clearly physicians can’t take every death personally. If we did, we would crumble under the weight of our responsibility, and some of us do anyways. Burn out in emergency medicine and intensive care medicine is strikingly higher than in other specialties. I suspect this has much to do with our frequent brushes with suffering and death. Because of what we see, it is untenable to view every patient as one would a close friend, family member our even as someone who resembles ourselves. On the other hand, medical negligence, both litigated and that of lore, is fraught with examples of doctors who viewed patients as physical collections of pathology and not as the precious wards they are. It’s a struggle to treat patients as one would want one’s own family member treated, while at the same time maintain the distance required to be an effective healer. What is the appropriate balance? I don’t purport to know the answer, neither for myself nor for anyone else. I do know, however, that this struggle makes me grow in ways I’m not sure I particularly like, and places a weight on my psyche that I don’t always know what to do with.

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