In the last few weeks, one question has been pressing against my consciousness with insistent force: since when did our patients become the Enemy?
It's an attitude I encounter almost daily-- when my residents use phrases like "OTL" ("Off the List," or more colorfully, "OTFL"-- or when in a particularly irate mood "OTMFL") to express their joy at finally having gotten rid of an especially troublesome patient. Or when they call patients "crazy" (or "fucking crazy"). Or when they make fun of an extensive list of psychotropic medications. Or when they make a beeline out of a patient's room before the patient has finished speaking, the sentences trailing off behind them without even a goodbye to punctuate.
I saw Ms. F this morning, a spunky woman who has a malrotation of the gut (a congenital defect that can cause bowel to twist up on itself and obstruct). She underwent CABG (coronary artery bypass grafting) 3 weeks ago, but her hospital stay has been complicated by small bowel obstruction and consequently a second surgery. When I entered the room at 5:30 AM, she was beside herself. Yesterday she had been able to eat clear liquids! And she had been walking all up and down the halls. She was so looking forward to finally being able to eat again, and to going home, but last night, in her sleep, she had palpitations. Her heart rate was in the 140's; the cardiology resident was called to manage her and she was set back, yet again.
I only had 15 minutes to spend with her, but by the time she was done telling me everything, I had been with her for 30 minutes. Honestly, what could I do to help her anyway? But I bet there was no one else in this whole damn hospital who could do what I did this morning for her-- spend a whole extra 15 minutes listening to how she felt horrible that she hadn't asked the nurse to call her husband in the middle of the night because what if something was critically wrong and she was about to die? He would be so upset! But she didn't want to wake him up, especially with his congestive heart failure, in the middle of this 5 degree winter night to come out in the cold to watch her sleep in the hospital. And she was so tired of being in the hospital, can you imagine being in a hospital for three whole weeks? And her left arm IV had infiltrated so it was moved to the right arm, but one of the IV lines had a long catheter that kinked when she bent her elbow, so her right arm had to be splinted to keep it extended, and now she couldn't even knit anymore to pass the time. And how she missed doing her hobbies, and having the freedom to do what she liked! I bet you're getting tired of reading this bullshit, aren't you?
By the time I got back to my team to make rounds, I was late, but I figured my residents would understand. After all, how horrible must it be to be a patient in a hospital! Can you imagine not being able to eat for a week? After all, we go around making patients NPO (nil per os, nothing by mouth) left and right all day long on a surgical service. Obstruction? NPO! Diverticulitis? NPO! Cholecystitis? NPO! Pancreatitis? NPO! We bandy NPO around like it's a free-for-all. But do we ever stop and think about what that means, physically and emotionally, for the people to whom we're doing it?
And blood draws. How about we come and poke you with a needle at 5 AM every morning for the next 2 weeks? Forget the hospital bed, we'll even do it in your home, see how that feels for you.
And resident rounds. Try waking up with a start to a crowd of 3 residents and 2 medical students arranged around your bed, talking about you. Because they were in too much of a rush to knock on the door before entering the room. That actually happens.
And those horrible plastic beds. Try sleeping in those for 2 weeks. Woken up every 4 hours to have a blood pressure measurement. Add a little bit of intractable pain to the mix.
I explained and apologized that I was late and hadn't written my note because my pre-round with one of my patients had taken much longer than anticipated. My senior resident nodded, understanding my plight. Ms. F was really not feeling well--
"Oh... Ms. F? She's fucking crazy!" He rolled his eyes with the air of an old soul sharing a dirty secret. The junior resident cackled, sycophantically. I had to pick my jaw up off the floor. She's crazy, I tried to reason. She's crazy because she can't shut up, can't stop complaining about not being able to eat. She's crazy because she's depressed about not being able to do what she loves. She's crazy because she feels guilty about worrying her husband! She's crazy because she can't stand incessant blood draws, being bed-bound, and not being able to eat. She's crazy because she's afraid. Try as I might, I couldn't make 2 and 2 equal 4. Flailing in the deep end, I cast about for any purchase I could find, and managed to lock eyes with the other medical student on my team. Together, we cringed; at once, I felt human again.
Patients are human beings too. Perhaps we forget it, in the sleep deprivation, the desensitization to how incredibly frightening and uncomfortable it actually is to be in a hospital. Perhaps we are dead to the mortality our patients are facing daily, because we see it every day without even a blink of sleep to break things up. I don't know what the cause is, but this is my greatest fear: that I will become like that someday, that I will forget how to empathize with suffering; that, caught up in my own tasks and troubles, I will have no energy left to be compassionate-- and worst of all, that I will be OK with it, laughing along with everyone else, cracking jokes at my patients' expense, any avenue to break up the tension inside me. I am afraid that in this struggle to become a surgeon-- superhuman-- I may somehow end up less than human.
Monday, February 11, 2008
Sunday, February 3, 2008
Surgery: Baptism
"So you want to go into Surgery?" asked Dr. H, elbows deep in a patient's abdomen. We were standing in the OR at 7:30 on a Sunday morning, and I imagined the rest of the world still gently asleep in their beds, early sunlight filtering quietly in through the windowshades. I had already been awake for three hours, and was in the process of being awarded for my diligence with the first of three emergency operations of the day. I had visited my patients in their beds in the dark morning, listened to their concerns, and created their plans for the day's work of healing. I had stood in my place at the end of the queue as the ritual of morning rounds wound its way around the hospital. I had participated in the flurry of action as a trauma patient (alcohol, car collision, rollover) was rushed to the OR, STAT! Changed into my green scrubs, I stood, flummoxed and breathless, as the attending and senior resident performed the magic of swashbuckling into a man's abdomen in a matter of minutes, a process that they called "controlled chaos," to get to the secret inside: a lacerated spleen that was rapidly hemorrhaging his life away.
Within minutes, the comment "spleen out" was followed by a maroon object which emerged from the depths of the abdomen to attend its own open-casket viewing in a blue, kidney-shaped basin. What a sad remnant of man's body, separated from him forever! The spleen had been slashed liberally across the face by the patient's own traitorous 10th, 11th, and 12th ribs, set free by fractures to wreak their havoc inside his abdomen.
"Get up here." Flustered, I moved my hands to where Dr. H was investigating loops of small bowel for injury.
"No, take my place. Now follow Paul as he works the bowel. Get your hands in there! You're responsible if he misses something!" Dr. H stepped away as I touched the bowel gingerly, several inches behind Paul, who was nonchalantly proceeding along the intestinal tract, smoothing, feeling, inspecting for signs of trauma.
"You move along, checking every inch of the bowel for damage; that's a standard procedure for trauma. You see where the bowel changes caliber here?" Indeed, the bowel changed perceptibly but indescribably at the point Paul was indicating to me. No amount of description in an anatomy textbook had ever revealed that secret to me so openly as this patient's body. "That's where the jejunum becomes ileum." We continued in this fashion for a time, companionably.
"You're still missing something," said Dr. H from the corner. He moved closer to me. Thrusting his hand into the bloody abdomen, he soaked my left hand and arm with the ooze.
"So you want to go into Surgery? There. Now, you're baptized."
Within minutes, the comment "spleen out" was followed by a maroon object which emerged from the depths of the abdomen to attend its own open-casket viewing in a blue, kidney-shaped basin. What a sad remnant of man's body, separated from him forever! The spleen had been slashed liberally across the face by the patient's own traitorous 10th, 11th, and 12th ribs, set free by fractures to wreak their havoc inside his abdomen.
"Get up here." Flustered, I moved my hands to where Dr. H was investigating loops of small bowel for injury.
"No, take my place. Now follow Paul as he works the bowel. Get your hands in there! You're responsible if he misses something!" Dr. H stepped away as I touched the bowel gingerly, several inches behind Paul, who was nonchalantly proceeding along the intestinal tract, smoothing, feeling, inspecting for signs of trauma.
"You move along, checking every inch of the bowel for damage; that's a standard procedure for trauma. You see where the bowel changes caliber here?" Indeed, the bowel changed perceptibly but indescribably at the point Paul was indicating to me. No amount of description in an anatomy textbook had ever revealed that secret to me so openly as this patient's body. "That's where the jejunum becomes ileum." We continued in this fashion for a time, companionably.
"You're still missing something," said Dr. H from the corner. He moved closer to me. Thrusting his hand into the bloody abdomen, he soaked my left hand and arm with the ooze.
"So you want to go into Surgery? There. Now, you're baptized."
Saturday, January 5, 2008
Surgery: Today Has Just Been One of Those Days...
Today has just been one of those days. You know, one of those days where you come in the morning all studied up and ready to scrub in on a radical cholecystectomy with liver resection and lymph node dissection (and ready to impress, having memorized all the staging systems and appropriate treatments and prognoses for gallbladder carcinoma), but end up getting diverted to a colorectal resection which starts out laparascopically but turns into an exploratory laparotomy (open surgery), and then the anastamosed (reconnected) colon somehow loses its blood supply and starts to die and you have to do it all over again with another piece of colon and now the patient has an ileostomy too and it was supposed to take 3 hours but it took 8... and then the second patient of the day who was supposed to go at 11 ends up going at 6 and has a carcinoma of the pancreas which has decided to wrap itself around the superior mesenteric artery thereby making it unresectable (read: we opened him up and couldn't take the tumor out anyway). And when it's all finally over at 11 PM you just want to shoot yourself so you don't have to come in at 5:30 AM again tomorrow morning.
You know... one of those days.
You know... one of those days.
Tuesday, November 6, 2007
OB/GYN: Bringing Forth Life
In real life, the uterus looks just like it does in picture books. Springing forth from behind a curtain of fat and abdominal muscles in the depths of an incised abdomen, it's a strange, almost whimsical shape which is easily recognized as "uterus!"-- even by the unseasoned medical student. On the inside, the uterus looks just like a blood-soaked sponge, and it's easy to imagine that if you were just to rinse and wring it out, it might be ready for another go on the kitchen counter.
These were my observations today on my first two C-sections. This operation is easily the most unique of the common operations: whereas it is extremely invasive, the patient is awake-- and very aware of what is happening to her body behind the sterile drape.
It all begins with a nervous mother-to-be seated on the operating table with her bare back to the door. Regardless of how fat or thin she may be, and despite the funny shower cap surgical hat she is wearing, I am struck by how beautiful she looks in her nakedness. This is her monologue under the bright OR lights; she is the quiet center of commotion as the OR staff prepare for the procedure.
The operation will involve up to 20 people, from OR staff to anesthesia to OB/GYN to pediatrics, each a perfect gear turning in time with its colleagues. An anesthetist sterilizes and drapes her back, then injects a spinal block. Her legs go numb, then limp; she loses pain sensation from her abdomen down. She is helped to rest on the operating table and draped: she becomes nothing but a vast blue sterile field with a hole on the abdomen. The freshly scrubbed obstetric team enters, dripping, and is gowned and gloved. The OR nurse hurries to set up her arrays of instruments. Pediatrics people shift impatiently from foot to foot next to the empty, expectant incubator. The stage is set.
From here, the plot thickens and becomes free to veer off wildly in unimaginable directions. She may be hugely pregnant and ready to burst with triplets... or barely showing with a 14 week premie who will tip the scale at scarcely more than a pound and make only faint, exasperated movements of the head and arms. The first incision draws superficial blood, some of it squirting skyward in its great eagerness to get out of her body. The underlying connective tissue is carefully dissected. The rectus muscles are revealed, glistening and taut. They are pulled violently aside by the obstetrician and his assistant to widen the sight line into the peritoneum; a maneuver that requires strength remniscent to me of the Army football team playing tug-of-war with Navy.
The uterus appears through the translucent peritoneum, protecting its precious cargo. Inside the soft muscle is a living soul preparing to enter the world. The rest of the operation is a blur because here the emotions begin to run high. After we enter the uterus, a gush of fluid (here I silently thank my lucky stars for choosing the mask with a face shield) signals rupture of membranes, and suddenly a grey, drowned rat is being pulled free from its mother's abdomen. I stand transfixed, shocked: it's almost like a scene from... what's that movie where the aliens take over human bodies and burst forth from their abdomens? The rat mews weakly. Mouth and nose suctioned. Quickly rubbed dry. Cord clamped and cut. Handed to mom. Tears rolling down her face. Her new child. The pediatrics team swarms in.
Our emotions spent, we turn our attention to undoing the hole we've made in mom's abdomen. And what a hole it is... her uterus hanging outside the skin, the muscles separated like a drawn curtain, blood everywhere. So we clean up our mess with what tools we have: sutures here, electrocautery there, more sutures, staples. What intricate handiwork! When we've finished, the neat incisional scar mocks the havoc we wreaked beneath it. We apply the white dressing, just to make further assurance that its tight lips will never divulge her secret.
I look over at the incubator several minutes later, and see that the rat has turned into a plump, pink infant. I can't help but smile behind my mask; it is only fitting that this first chapter of life makes such a traumatic, exuberant, and eloquent preface to all the rest. Happy birthday, kid.
These were my observations today on my first two C-sections. This operation is easily the most unique of the common operations: whereas it is extremely invasive, the patient is awake-- and very aware of what is happening to her body behind the sterile drape.
It all begins with a nervous mother-to-be seated on the operating table with her bare back to the door. Regardless of how fat or thin she may be, and despite the funny shower cap surgical hat she is wearing, I am struck by how beautiful she looks in her nakedness. This is her monologue under the bright OR lights; she is the quiet center of commotion as the OR staff prepare for the procedure.
The operation will involve up to 20 people, from OR staff to anesthesia to OB/GYN to pediatrics, each a perfect gear turning in time with its colleagues. An anesthetist sterilizes and drapes her back, then injects a spinal block. Her legs go numb, then limp; she loses pain sensation from her abdomen down. She is helped to rest on the operating table and draped: she becomes nothing but a vast blue sterile field with a hole on the abdomen. The freshly scrubbed obstetric team enters, dripping, and is gowned and gloved. The OR nurse hurries to set up her arrays of instruments. Pediatrics people shift impatiently from foot to foot next to the empty, expectant incubator. The stage is set.
From here, the plot thickens and becomes free to veer off wildly in unimaginable directions. She may be hugely pregnant and ready to burst with triplets... or barely showing with a 14 week premie who will tip the scale at scarcely more than a pound and make only faint, exasperated movements of the head and arms. The first incision draws superficial blood, some of it squirting skyward in its great eagerness to get out of her body. The underlying connective tissue is carefully dissected. The rectus muscles are revealed, glistening and taut. They are pulled violently aside by the obstetrician and his assistant to widen the sight line into the peritoneum; a maneuver that requires strength remniscent to me of the Army football team playing tug-of-war with Navy.
The uterus appears through the translucent peritoneum, protecting its precious cargo. Inside the soft muscle is a living soul preparing to enter the world. The rest of the operation is a blur because here the emotions begin to run high. After we enter the uterus, a gush of fluid (here I silently thank my lucky stars for choosing the mask with a face shield) signals rupture of membranes, and suddenly a grey, drowned rat is being pulled free from its mother's abdomen. I stand transfixed, shocked: it's almost like a scene from... what's that movie where the aliens take over human bodies and burst forth from their abdomens? The rat mews weakly. Mouth and nose suctioned. Quickly rubbed dry. Cord clamped and cut. Handed to mom. Tears rolling down her face. Her new child. The pediatrics team swarms in.
Our emotions spent, we turn our attention to undoing the hole we've made in mom's abdomen. And what a hole it is... her uterus hanging outside the skin, the muscles separated like a drawn curtain, blood everywhere. So we clean up our mess with what tools we have: sutures here, electrocautery there, more sutures, staples. What intricate handiwork! When we've finished, the neat incisional scar mocks the havoc we wreaked beneath it. We apply the white dressing, just to make further assurance that its tight lips will never divulge her secret.
I look over at the incubator several minutes later, and see that the rat has turned into a plump, pink infant. I can't help but smile behind my mask; it is only fitting that this first chapter of life makes such a traumatic, exuberant, and eloquent preface to all the rest. Happy birthday, kid.
Saturday, October 20, 2007
Medicine: "And I hate when things are over...there's just so much left undone." -Breakfast at Tiffany's (Deep Blue Something)
Hello my lovelies, long time no see! It's been a while since my last entry, be it a testament of how busy Medicine has kept me or how bad I am at multi-tasking. In any case, it's the day after Medicine is over and time to reflect on the past 8 weeks, so without further ado...
I want for you to share this feeling with me. It's somewhat described by the following metaphor: When we first get these new sneakers, they're unfamiliar and uncomfortable, needing some breaking in. But since they're still shiny and novel, we're excited to wear them anyway. We wear them in for a while, finding moments that they're hard to keep on. In time, we discover the magic (aka sticking power) of velcro and apply them to our sneakers. There! Much easier but somewhat awkward-looking. So we continue to look for a better way to keep these sneakers on. Eventually, we learn how to tie the shoe laces and no longer need the velcro. Now we're really walking confidently and effortlessly (relatively speaking...). For a while that's what we do, until the end when someome tells us too soon that it's time to get a new pair. As fun as that sounds, we're now comfortable...and perhaps attached...but we reluctantly give these up, and ready ourselves for the next pair.
If the above made absolutely no sense, all I'm trying to say is that I'm going to miss Medicine.
...to be continued...
I want for you to share this feeling with me. It's somewhat described by the following metaphor: When we first get these new sneakers, they're unfamiliar and uncomfortable, needing some breaking in. But since they're still shiny and novel, we're excited to wear them anyway. We wear them in for a while, finding moments that they're hard to keep on. In time, we discover the magic (aka sticking power) of velcro and apply them to our sneakers. There! Much easier but somewhat awkward-looking. So we continue to look for a better way to keep these sneakers on. Eventually, we learn how to tie the shoe laces and no longer need the velcro. Now we're really walking confidently and effortlessly (relatively speaking...). For a while that's what we do, until the end when someome tells us too soon that it's time to get a new pair. As fun as that sounds, we're now comfortable...and perhaps attached...but we reluctantly give these up, and ready ourselves for the next pair.
If the above made absolutely no sense, all I'm trying to say is that I'm going to miss Medicine.
...to be continued...
Saturday, September 15, 2007
Medicine: R/O Radiology
Today, I went down to Radiology to get a preliminary reading of a CT on a patient. I had never been to where the radiologists work before. I've heard all sorts of jokes about how if you're afraid of the dark you should go into ophthalmology, and if you're afraid of the light you should go into radiology, but I've never seen what it's like firsthand. Now I know that I never want to go there again. The radiologists sit in the dark (and I'm not even kidding in the slightest here) in a large, labrynthine room of cubicles, each with 2 huge flat screen computer displays. They stare at the computer screens in the dark. All day. I can officially say that within the first 30 seconds, radiology was ruled out as a career for me-- if I wanted to spend the rest of my life sitting in a dark cubicle staring at a computer screen, I could have skipped the 4 wasted years of youth in med school and $150K of debt, and started off at twice the salary I'm going to make as an resident using my Bachelor's degree as a computer programmer.
Radiology? An emphatic noooooo, thank you.
Radiology? An emphatic noooooo, thank you.
Monday, September 10, 2007
Medicine: My First Brush with Cancer
I am proud to announce that in the last 2 weeks, I have figured out how to get from South Building to 4-West, not just what a sign-out is but also how to do it, and settled neatly into my spot at the bottom of the medical totem pole. I still do the 180 outside every elevator, though. I don't think I'll ever be able to kick that ritual. I followed my very own patient from a quivering wreck on Dilaudid in the ER through to happy, ambulating discharge 4 days later, and although everyone else on my team got a handshake, I was the only one who got a hug (I'm unabashedly proud of that-- and it was a big, badass guy, not a touchy-feely little old lady). I feel integrated. I feel like I am actually making a difference.
Midway into week 2, I was asked to "look up" rare coinfections with Lyme disease (namely, Babesiosis and Ehrlichiosis for those who care for such pedantry). Ehrlichiosis presents with fevers, myalgias, thrombocytopenia (low platelets), and elevated liver enzymes. I don't believe I will ever forget the symptom complex for Ehrlichiosis, because a patient came in that very morning with a symptom complex and history of present illness so definitive for Ehrlichiosis that we might as well have watched the tick bite him. He was our Ehrlichiosis patient. Or was he?
We began the standard treatment regimen with doxycycline and sent his blood out for serology at a lab in Utah-- the only lab in the country that performs the blood test for Ehrlichiosis. His fevers and joint pains went away, and then returned with a vengeance. Despite the appropriate treatment, his blood labs continued inexorably on their negative course. He was in pain, a pathetic body on the bed, sweating and asking us daily why we couldn't do anything. We increased his pain medication. We gave him laxatives. We increased his pain medication some more. We waited for the serology to return, to confirm the diagnosis we were so sure was true.
Our patient's condition continued to worsen. Confidence in our diagnosis waned to hope against hope, because by this time, we had widened our differential diagnosis and set up plan B: if our serology for Ehrlichiosis came back negative, we would have to start thinking cancer. We would go where the money is and biopsy the bone marrow. Our patient had stopped looking like the classic case of Ehrlichiosis and started looking just like an atypical presentation for leukemia or lymphoma-- and we had ruled out almost everything else.
One morning, his daily blood count came back with "atypical lymphocytes" on the smear (under the microscope). A marrow biopsy was performed the very next day. As we began preparations for transfer to the Hematology-Oncology service, our Ehrlichiosis serology fell by the wayside, forgotten. I don't even know what the results are, if they ever came back; I assume they were negative, but it really didn't matter anymore.
It was almost a blur how quickly he was gone from our service, whisked up by Oncology into a world of immediate chemotherapy, considerations for bone marrow transplantation, and months of suspense about whether he would live or die. I would have imagined that a patient diagnosed with cancer would need weeks to come to terms with the diagnosis before he could begin to undergo chemotherapy. In reality, things move at a breakneck pace; there was barely time to turn around, blow a kiss, and wave before this huge change took over his life. But time is a mysterious beast; inside my patient's mind, life may have turned to slow motion. I don't know.
I think I learned 2 important lessons from this patient's case. The first is a principle I was taught in the abstract last year: YCMTDIYDTOI. What the heck does YCMTDIYDTOI mean, you ask? Well, its name illustrates its principle: You Can't Make The Diagnosis If You Don't Think Of It (and you certainly can't figure out what this acronym stands for if you don't already know it-- and think of it). The best clinicians have been said to use pattern recognition, but sometimes patterns are not the be all and end all of diagnostics. Solving problems in the real world is totally different from solving textbook cases in my first and second year lectures, where anyone who had pneumonia came in with a cough, a fever, and a dullness to percussion over the right lower lobe. You have to start somewhere-- but from there, you must grow.
The second, and more important, lesson I learned from this patient is that cancer is never expected. Nobody comes into the hospital thinking "I must have cancer." It is sobering to know that at any point, any one of us could walk in with a fever and some aches, and walk out with a diagnosis that might change our lives. The line between health and illness is finer than I had ever appreciated, and every step we take on the side of health should be a thankful one. When we do cross that line, we won't know how far we've gone-- whether we'll be cured in a week with antibiotics, or whether life will start being measured in probabilities of survival months. The journey is seldom in black and white, and it is always frightening and confusing. It's a good lesson for me to have learned now, because I will spend the rest of my life escorting my patients along that road.
Midway into week 2, I was asked to "look up" rare coinfections with Lyme disease (namely, Babesiosis and Ehrlichiosis for those who care for such pedantry). Ehrlichiosis presents with fevers, myalgias, thrombocytopenia (low platelets), and elevated liver enzymes. I don't believe I will ever forget the symptom complex for Ehrlichiosis, because a patient came in that very morning with a symptom complex and history of present illness so definitive for Ehrlichiosis that we might as well have watched the tick bite him. He was our Ehrlichiosis patient. Or was he?
We began the standard treatment regimen with doxycycline and sent his blood out for serology at a lab in Utah-- the only lab in the country that performs the blood test for Ehrlichiosis. His fevers and joint pains went away, and then returned with a vengeance. Despite the appropriate treatment, his blood labs continued inexorably on their negative course. He was in pain, a pathetic body on the bed, sweating and asking us daily why we couldn't do anything. We increased his pain medication. We gave him laxatives. We increased his pain medication some more. We waited for the serology to return, to confirm the diagnosis we were so sure was true.
Our patient's condition continued to worsen. Confidence in our diagnosis waned to hope against hope, because by this time, we had widened our differential diagnosis and set up plan B: if our serology for Ehrlichiosis came back negative, we would have to start thinking cancer. We would go where the money is and biopsy the bone marrow. Our patient had stopped looking like the classic case of Ehrlichiosis and started looking just like an atypical presentation for leukemia or lymphoma-- and we had ruled out almost everything else.
One morning, his daily blood count came back with "atypical lymphocytes" on the smear (under the microscope). A marrow biopsy was performed the very next day. As we began preparations for transfer to the Hematology-Oncology service, our Ehrlichiosis serology fell by the wayside, forgotten. I don't even know what the results are, if they ever came back; I assume they were negative, but it really didn't matter anymore.
It was almost a blur how quickly he was gone from our service, whisked up by Oncology into a world of immediate chemotherapy, considerations for bone marrow transplantation, and months of suspense about whether he would live or die. I would have imagined that a patient diagnosed with cancer would need weeks to come to terms with the diagnosis before he could begin to undergo chemotherapy. In reality, things move at a breakneck pace; there was barely time to turn around, blow a kiss, and wave before this huge change took over his life. But time is a mysterious beast; inside my patient's mind, life may have turned to slow motion. I don't know.
I think I learned 2 important lessons from this patient's case. The first is a principle I was taught in the abstract last year: YCMTDIYDTOI. What the heck does YCMTDIYDTOI mean, you ask? Well, its name illustrates its principle: You Can't Make The Diagnosis If You Don't Think Of It (and you certainly can't figure out what this acronym stands for if you don't already know it-- and think of it). The best clinicians have been said to use pattern recognition, but sometimes patterns are not the be all and end all of diagnostics. Solving problems in the real world is totally different from solving textbook cases in my first and second year lectures, where anyone who had pneumonia came in with a cough, a fever, and a dullness to percussion over the right lower lobe. You have to start somewhere-- but from there, you must grow.
The second, and more important, lesson I learned from this patient is that cancer is never expected. Nobody comes into the hospital thinking "I must have cancer." It is sobering to know that at any point, any one of us could walk in with a fever and some aches, and walk out with a diagnosis that might change our lives. The line between health and illness is finer than I had ever appreciated, and every step we take on the side of health should be a thankful one. When we do cross that line, we won't know how far we've gone-- whether we'll be cured in a week with antibiotics, or whether life will start being measured in probabilities of survival months. The journey is seldom in black and white, and it is always frightening and confusing. It's a good lesson for me to have learned now, because I will spend the rest of my life escorting my patients along that road.
Subscribe to:
Posts (Atom)