Friday, March 27, 2020

End in Mind.. - Part I

 I have been maintaining a log of some memorable patients and families - some I would be happy to never set eyes/ears on, and some I would love to see outside of the hospital under different circumstances! So here goes. 

But first, a disclaimer: This post, I dedicate to the people who have died on my watch. The identity of the individuals have been changed to maintain privacy. I will share this in 2 parts. Ideas and opinions expressed in this post are my own, shaped by my own experiences. They do not reflect the opinions of my colleagues who may have had entirely different experiences than me under the same system and at the same time. 

1.       Mrs. K – 60 yo delightful lady from Ghana, suffering from widely metastatic cholangio-carcinoma. I had been taking care of her for 2 whole weeks, before she started slowly slipping away. It was challenging to navigate family dynamics between a jerk husband and her devastated sisters. Unfortunately, healthcare doesn’t recognize the power of the human heart; just a worthless signature on the dotted line. The husband was the legal surrogate healthcare decision maker. The one word of advice I kept getting from my supervising Attending was to not get involved in family dynamics. That wasn’t a part of my job. My job was to take care of Mrs. K. What baffled me about this way of thinking was the underlying assumption that taking care of Mrs. K physically and emotionally, was mutually exclusive from enforcing that her dying wishes were honored by the surrogate decision maker. I will never make peace with the fact that I could not reassure her that her wallet and her diary, wrapped in a red plastic bag that she kept under her pillow, would not fall in her husband’s hands, but would be delivered to her 11 yo daughter. When she finally passed on and I was called to the bedside to pronounce her dead, I walked in with as much dignity as was expected of me and asked the husband to step out as I did a confirmatory exam. I finally pronounced her dead at 2:47 pm that afternoon, walked out the door as her husband stepped in, and promptly collapsed. Her sister, who was standing quietly by the door, walked over and tightly held my hands. For what seemed like an eternity, we could not speak, mutually connected in our shared angst at what had transpired these last few days. Finally, she helped me to my feet. And in that split second before her husband came barging out, I pushed the red plastic bag in her hands, as she looked me in the eye one last time and quickly walked away. 

2.       Mr. Mandeerf – 77 yo gentleman also with metastatic cholangio-carcinoma, but presenting very differently from Mrs. K (I won’t go into the clinical details here of course). This guy came walking into the hospital. Very walky-talky for the first few days of his stay. And then it started. A slight ache here. A little bleed there. And so it went, until we all realized it was time for the dreaded family conference. Typically, this can take varied forms depending on how close or far apart you are on an emotional/intellectual scale with the family members. The tone of these meetings completely depend on the temperaments of the family members. I have witnessed several meetings where entitled families think it is their birthright to yell/kick chairs/ and in general behave like uncouth hooligans (“Dozy old bugger”, as Celia from the new Netflix drama might say). Anyhow, for Mr. Mandeerf, his family was his wife and 2 grown up sons. One living here but sometimes working out of Minneapolis! The other one on phone from New York. The nicest family I have interacted with by far! Not to mention that having a gorgeous son in the room never hurts! I have often wondered whether it was because of my fondness for Mr. M and his wife or the presence of their son that made me spend disproportionate amounts of time with this family! Countertransference is a thing, people! 

Anyhow, what I remember most is the family conference I had with his wife and sons. The Attending was happy to let me drive the conversation because I was the one who knew the family best. Prior to the meeting, the Attending went over the exact algorithm for breaking bad news to families. We had a signal planned out for when I needed him to intervene. I took a deep breath and walked in. Mrs. M was sitting on the couch by herself, so I sat next to her. Gorgeous son drew up a chair right up close and had his brother on speaker phone. For a moment I considered asking him to move back because I was having trouble catching my breath (no kidding). I didn't. My Attending sat in a corner. I looked down at my notes and then I looked at Mrs. M and took her hand, unsure where to begin; and the most wonderful thing happened. I had the near-perfect conversation with this family, helping them decide whether to switch their loved one to comfort cares or whether to continue pursuing aggressive measures. And I did it without actually following the algorithm that I had learned by rote. It just came so easily to me. I felt  comfortable in that space, in my role, in my shoes. It just felt right. And I realized it wasn’t me. It was them. How a family meeting will go, completely and totally depends on the family we’re interacting with. Our role as physicians is not to enforce; not to project our opinions; but simply to listen and to provide enough information for the family to make an informed decision. That is all. That is as simple as it gets. Only not.. 

More on this in Part II. 

Tuesday, March 24, 2020

It was the best o times, it was the worst of times...

Disclaimer: LONG post!

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us”  - Charles Dickens

Truer words couldn’t have described my first year at Duke. Oh, what a roller coaster ride this has been. I am finally at a good place in my head where I can sit back and reflect. Not get angry. Not feel disillusioned. Not lose hope. For sure, it has been a mixed bag of experiences. And at the end of long weeks and longer nights, overworked weekends, missed family dinners, 80+ hours of constant physical/emotional turmoil every week for the last 40 weeks for more, I am finally at a spot where I can stand back, take a deep breath, and finally begin to share my journey.

An insane amount of time has passed since I last wrote down my thoughts. As some of my readers might be knowing, I am now training to be a Neurologist (this year I’m training in Internal Medicine). I have longed to be where I am today. I have worked so hard to be here. And I never for a moment stopped to wonder what I am giving up in the process, what I have or will sacrifice along the way. I only focused on getting here because this is what I wanted so very much! So, when I was recently asked this question, it startled me! It made me uncomfortable. And I haven’t stopped thinking about it ever since. I’m a little taken aback by how viscerally I reacted in that moment. Not as if I keep my acerbic wit all fueled up, just in case. So, I wasn’t able to slither out with the smug satisfaction of a handy repartee! But I cried to myself that night, something I can’t remember having done in many years! The truth is I started thinking of myself, of this endless journey I am on, of my own loss of self over different relationships (some completely worthless to begin with!), and of the loss of my Dad. I guess it might have been because after a stressful day at work, I broke my glasses earlier that evening without a spare one in store! Or perhaps, I was just feeling sorry for myself. Whatever it was, I realized that not talking about something doesn't necessarily mean it’s gone. So, here I am today. 

There is one particular moment from the tv show Scrubs that has always fascinated me. JD bolts down the hallway to the jarring notes of his code pager. Two seconds later he is seen vying for a safe space in a supply closet with his co-intern. It was only during the recent ICU rotation that I realized how legitimate those feelings were. I could finally relate to the despair, the urge to bolt, and yet being frozen to the ground in fear of failing.

Flashback to the med school years (which now seems a lifetime ago), I remember sitting through a cardiology small group meeting one afternoon. We were learning to recognize ECG patterns and come up with differentials. At one point when we were shown a ventricular fibrillation pattern, (as sinister as it gets), the resident asked what we would do. And I remembered that moment from Scrubs and thought we could run the other way of course! From where I stood at that moment in time, handling a hypothetical cardiac arrest situation seemed easy, even funny enough. I laughed to myself. 

These last few months have been a lesson in humility. A reminder of my own inadequacy in this long path to finally becoming a doctor. I have had my fair share of hiding in metaphorical closets of course. I have often chosen simpler cases which required minimal effort on my side. Other times I have deferred opportunities to others who were more excited than me. I have struggled with a desire to impress versus an inherent fear of failing. And I have shamelessly exploited the privilege of my position in the larger scheme of things: I am a resident. Let me ask the Attending. 

I have learned to give up on the extra half hour of early morning sleep, to be able to pour over patient charts. I’ve learned to juggle a million things in a way that also ensures steady state learning. I’ve learned to dress so as to accommodate any and all medical paraphernalia on self at all times. But most of all, I've learned to spend the last moments of a regular hospital shift, saying goodbye to my patients for the day. I did not know back then, as I do now, that I would soon learn to depend on my patients for a glimmer of hope. I did not know that the constant grueling reminders of one’s incapability and the long struggle that lies ahead, would instantly wash away in the comfort I would find in their words. That I would find my safe zone in their presence soon enough.

But, as I mentioned before, it’s been a mixed bag really. There were times when I was so angry and so ready to explode, and I did. There were times when I have cried over the loss of a patient and have had a family member console me! There were times when I have entered the hospital wishing someone was dead so I didn’t have to deal with his angry family! It has indeed been a crazy roller coaster of a ride. And now of course, here we are in the midst of a global pandemic! These are difficult times. These are scary times. Unprecedented. Once in a life-time kind of thing. I would like to think that I am making a difference by fighting the good fight. There are some who are hailing healthcare workers at the front lines as heroes. And there are some who are disgusted with everything and everyone healthcare, as always. To them I say, please come do our jobs for us if you think we are incapable. It’s easy to raise your voices from the comfort of home. Please try spending one day in my shoes. Just one fucking day..

So, you see, I have come a long way. Slowly, piece by piece, I learned to maneuver my way around the maze with customary aplomb. Overnight, almost spectacularly, I found myself in a new terrain, where I was confidently admitting my own patients, proposing plans that went largely unedited, and discussing treatment choices with families at the bedside. Almost overnight, I found myself turning into the doctor, and the person I have worked so hard to be.

Of course, right now there are multiple layers of buffers in place to protect us from our own ignorant fervor. But I am the first contact for my patients; and I will/have felt the personal weight of my assessments in very intimate ways. I have been called upon to take decisions of unthinkable impacts and I did not know what to do. But I always (mostly) tried to do what’s right.

And that, I imagine, is the force that has sustained me and all my friends through these years, and I hope, will continue to sustain us for a lifetime as physicians. Through all the long hours and missed holidays, through times of indecision and misjudgments, through petty resentments and frustration, through lost relationships - as we watch our lives pass us by - there has been this palpable certainty humming blithely underneath it all. We are still standing with our heads held high, because we believe we are here to do right by our patients. This is what inspires us, grounds us.

Of course it has been frightening, even blatantly miserable at times. We’ve witnessed tremendous suffering, known vulnerability and helplessness, and been privy to human frailty in its ugliest of forms. And not a single day has gone by when we have not been yelled at or walked all over by rogue family members in some form or the other. 

But we have chosen this journey for a reason. Even when we have to stand by and be easy targets, even when we are over-worked and sleep-deprived as I am right now, even when I’m wondering if I can/should explode and I have. Even in those vulnerable moments in training, I hope we have the foresight to make good calls, the wisdom to seek out others when we need them, and the fortitude to always run in the right direction.

P.S -  Just a heads up - Since I now find myself with some free time on hand for a day or two (!!!), I will post stories of my hospital encounters here. So keep an eye out, for those few who're still interested!