“How are you feeling today, Mr. B?”
“With my hands!”
“Can you tell me your full name?”
“B.D.”
“Great! And where are we right now?”
“I’m in my chair! Where are you?”
Pleasantly demented.
That’s how B was described in the initial history and physical, and it held true on the 3rd day of rounding on him during his hospital stay. Every morning we danced this dance – me asking the same orientation questions to person, place and time, him going through the same work-arounds to get me to divulge the answers.
What a cruel joke his form of dementia was – he couldn’t retain the knowledge to know where he was in space and time, yet he was with it enough to play this game with me every morning.
“I’m here standing in the same building as you, Mr. B. Do you know what type of facility this is?”
“I don’t know.. but the food here is terrible!”
“I’m sorry to hear that. Do you know what the day is today?”
“I don’t know.. when you get to my age, all the days run together. It’s 2000 something. Who are you anyway? Why are you asking so many questions?”
“I’m Dr. M. I’ve been seeing you every day for the last 2 days, and we’re in the hospital. You were having a hard time breathing but it looks like you’re getting better. We may be able to send you home tomorrow.”
“Oh… I remember you. You’re the nice one. Say… can you get me something better to eat? You can say it’s doctor’s orders!”
The transparency of his flattery to get his request granted pulled a smile out against my better judgement. A feeling of déjà vu swept over me as I realized I was rehashing the same conversation I just had with a 5 year old patient, but now with 89 year old B.
“I’m sorry, sir… I can’t do that for you. You might choke on more solid food, and you’ve already aspirated and gotten pneumonia from it.”
“Oh,” he said with downtrodden eyes, slumping over in his chair.
In a brief moment of clarity, B looked up searching for my eyes and asked,
“Is this how they want me to live the rest of my life? Why won’t they let me enjoy even the simple things like eating?
This is all I have left.
WHY, doc?”
Walking out of the room after examining B, I attempted to leave the unease enveloping me at the door.
Just shake it off, M. His heart failure exacerbation is almost resolved, he’s on antibiotics for aspiration pneumonia. You’re tee-ing him up to go home. You did your job.
After you sign off on that discharge summary, you never have to think about him again. This is why you chose this work.
Despite the self-cajoling, his plea continued to echo in my mind the rest of the day.
“WHY doc?”
Because your daughter’s not ready to let you go.
We’re not ready to let you go.
So we’re going to take away what little joy you might have in your day because we’ve somehow decided the meaning of life is to simply exist.
Know thyself
After just a month of hospitalist work, my fears about this job have been validated.
Even as a resident, I recognized the lifetime of futility working in a hospital would bring.
Running around during 12+ hour shifts while putting out fires left and right, selecting life saving medicines with the click of a button, coordinating care with specialists to pull patients back from the edge where life and death collide – the thrill of instant gratification is something that can’t be denied.
But when you take a step back, what did we really accomplish?
We move the needle from acutely decompensated to compensated.
We stabilize and ship patients out to their next facility where we make promises that they’ll eventually get better.
But better to us does not mean the same as better to them.
We know the majority will likely never achieve their previous level of “wellness”.
So we wait until the next time they bounce back to the hospital.
Decompensated → Compensated.
Lather → Rinse → Repeat.
Thanks to modern medicine, we have successfully prolonged the lifespan of multiple disease states.
But are we actually promoting living?
What if we have this all wrong?
What if life exists beyond the “fixing” of our 20+ problem list?
What if eating a steak in peace is what allows B to #livehisbestlife?
What if that could really be “doctor’s orders?”
***
I realize I have been really erratic with my weekly posts recently – working this new hospitalist schedule, I can’t seem to keep track of when Wednesday is (so much for being A&O x 3 myself!).
If you’d like to be notified by email when the next post goes up, feel free to sign up here:
Photo taken of clouds rolling in over Lake Tekapo, NZ in sync with waves on the shore of this glacier lake.
Beautiful photo. I missed you not being part of my Wednesday routine. 😉
Truthfully, one of the aspects of my job as an interventional radiologist was my forced participation in what I would call “futility medicine”. Unlike a surgeon, who gets consulted to assess patients in the context of procedures, has some input, can discuss with the family, and turn down absurd requests, in my world, someone would write or click on an order for “nephrostomy”, for “gastrostomy” for “visceral angiogram”, etc. and it was the expectation that I would do the job. It did not matter if I believed it should be done, my job was to “Just Do It!”, like in the Nike ads.
Too often, the context was along the lines of everyone in the chart agreeing that there was nothing more to be done for the 85 year old in multi organ failure, but Dr. X, out of nowhere comes up with a highly technical, challenging, and almost certain to fail procedure for the VagabondMD to try. Hey, why not? We are on our way to the morgue anyway, maybe IR can turn this around. These sorts of scenarios were not uncommon and were a great source for professional dissatisfaction.
Nowadays, I mostly look at pretty pictures, more a distant observer and documenter of the human condition and its disease states. “Wow, look at that enormous 1.5 cm CBD stone!” exclaimed me two nights ago, while chatting with a gastroenterologist, in reference to an 89 year old woman, in the ICU with ascending cholangitis. In a previous professional life, there was a decent chance that the patient would become my challenge. Today, it belongs to someone else.
Ah, sorry.. to be honest, the thought of being part of your Wednesday routine gives me so much guilt when I DON’T have a post that it compels me to actually restart writing when I have a moment! Just thought you should know 🙂
I ask myself every shift if I’m making things harder than they need to be. Do I need to be the one establishing goals of care every . single . time?? Do I really need to call up the family members and make sure everybody understands the futility of what we’re doing for their 90 something yo family member with multi organ failure? I probably have put in more palliative/hospice consults than any of my counterparts.
I really do think that me trying to put my foot down on these ridiculous things that we do, combined with the lack of sleep is just driving me to insanity. Not sure what my path to scaling back is going to look like since I don’t have any procedures that I can say, “No way!” to, but beating my head against the medical machine is a sure way to exhaustion.
No worries re: my Wednesday routine! I am not sitting around refreshing my email every 30 seconds, and I’ll take the blog when I can get it!
Scaling back may eventually mean doing fewer shifts. I have found that the annoyance factor with work is non-linear, but perhaps a squared or cubed relationship with the amount of work you do. When you cut back on the amount of work you do the aggravation seems to scale back quite a bit more. And then you also have more time to recover and refresh. Probably not in the cards for you now but hopefully down the road.
Student loans should be done in a year and the day those are paid off, this game completely changes. I’ll likely cut back significantly. There’s still light at the end of the tunnel… even if it’s me shining the light there myself!
Second Vagabond’s motion to consider cutting back if the aggravation gets out of hand. All those in favor…
Aye 🙂
It’s a thing that’s going to happen in the next 2 years for sure.
Hope you had a good trip to NZ.
Nice to see you back in the mix.
Your post definitely touches a lot of subjects that will never have satisfaction for everyone involved. Family doesn’t want to let someone elderly go. Elderly does not want to continue on like this. Etc.
It is a tough predicament to be put in. That’s why advanced directives are a good step but even in this case would not amount to much as the patient is not on life support.
When I was in primary care, I always tried to start those conversations in the office when the patients were still able to participate in these discussions in a low pressure environment. The frustration is that since our EMR didn’t talk to any of the nearby hospital’s EMRs, things would happen that I knew my patients wouldn’t have wanted to happen.
It’s always that estranged, prodigal relative that changes things at the last minute…
Sometimes we become warehouses for the guilt others cannot bear.
Such beautiful and apt imagery.
I may steal this…
M,
This is the frustration of shift work in our current system. You make your widget well, but never feel like the work gets completed, or wonder if the work shouldn’t be done in the first place. Except our widget is a human being, and we can’t shake the feeling that we aren’t doing them justice. Yet, what is the other realistic option? Maybe DPC, maybe something else entirely. But working less is probably part of the equation.
Absolutely. I don’t know how you’ve been able to continue for as long as you have, but the shift work is getting to me. However, I was presented with an opportunity last night by a fellow colleague that could relieve that itch for continuity of care and meaningful work.
We’ll see what happens! If all fails, at least I have a vacation coming up in T minus 1 day and have started to jam my summer schedule with quality time with friends and family. If fulfillment isn’t going to come from work, then I can make it about other things 🙂
We do what we can do and we don’t do what we can’t. We can’t stop time. We can’t change the course of entropy. We’d be foolish to try. We can like a Gondolier guide, protect and attend the one entrusted to us. Protect them from estranged family. Protect them from hospital administration. See to it the T’s got crossed in the face of an arrogant system that demands the expedience of no crossed T’s. That’s what we do. We can modify the probability and then we go home and build a life. A life for our spouses a life for our children a life for ourselves.
There is a device called a Galton board devised to show how the normal distribution works. You can YOUTUBE it. Pretend you are a ball at the top of the board. How is it some balls wind up going right and some left? What controls that? How did you wind up 2 SD toward success while so many others in your high school class wound up on the other side of the mean, the other side from the side you occupy? If you think it was random you’d be wrong. It’s the sum total of directed randomness. Once you get 1 SD to the positive your chances of failure diminish and eventually vanish. That’s what we do for our patients, we change their odds and direct the randomness and that’s all we do. We don’t control the chaos, merely slightly change the probabilities for the good. If you think you have the power to control the chaos you’re delusional. There is no future in being delusional.
My mother is 89 she has a 1.5% chance of living to 100. The entropy is encroaching. The comfort is I’m there to see to she she has as good as she can have in the face of the chaos. That is my power. Out of randomness can come predictability.