Humane human III
Another year goes by. Like wine, residents ferment and get better with time, and entering the familiar MICU environment, I have opinions and I bitch because I think I have the right.
I spend several weeks growing bossiness by way of brutal calls, septic patients, aggressive management, and steep learning curves.
One night, I get called right as I'm fluffing my pillow in the "palace" (the senior resident callroom) at midnight. Apparently, a floor team attempted to manage the hypotensive man all day, but now it has become evident that he would need critical care.
I wake up my intern. We are encountered with an orange orange man. One of the most orange I had ever seen, and I have seen a LOT of orange men, I tell my intern.
His story is, he was diagnosed with a "tumor" over 6 months ago at another hospital. Recommended a workup, and a biopsy, set up with an oncologist. He was discharged and never came back.
3 months ago, again, he was diagnosed at another hospital, this time, with a "likely pancreatic cancer," via some brushings from his biliary system, and again, discharged to follow up with a cancer doc, and never came back.
Now he finally showed up at our hospital, looking like a carrot, and with clear signs of liver failure. Bulging belly, low blood pressure, and, of course, deep jaundice.
I know SO much aggressive medicine. I've been practicing it all year and all month. Plus, this is right up my alley, being a GI case. I know this is not good news. But I know what to do. We'll place a line, work up the hypotension for sepsis, pump some big gun antibiotics, fix the thinned blood with a little vitamin K, consult GI in the morning for placement of stent to relieve his horrendous jaundice. I have a plan.
In the morning, I present the patient to the team. Incidentally, happens to be the same attending as the one who witnessed the Cambodian grieving family with me. I lay out the whole story of how this man tried to evade medical intervention for months and the tragic point to which this had brought him. I propose my carefully thought out 10 step plan of managing his liver failure, biliary obstruction, possible infection, his low blood pressure, coagulopathy, fluids, electrolytes, nutrition, and even prophylaxis.
The attending says....
"WHY?"
"Why... what?"
He says, "Think about it."
I sit down. Post call, I don't participate in the rest of rounds. I have time to think about it. I step back, away from the trees to try to see the proverbial forest. Pancreatic cancer. Orange man. Evading medical management, which, by the way, is useless and painful in this case, for 6 months. I've got him in a MICU bed pinned down, like a mouse in a trap, by the neck with an internal jugular catheter. We're not letting him eat, or drink, and he pees via a catheter.
The family wants to talk to me. I think again about my 10 step plan.
Open posture, open ended question, sympathetic angle of head, don't use the word 'disease'...
"What do you understand so far about the condition...." 3 pairs of eyes.
"Just tell us what's going on!" frustrated daughter.
I sigh.
"By all the information I have so far, your father has what looks like a pancreatic cancer. We don't have a tissue biopsy, which is what we'd need for a definitive diagnosis, but we have brushings from 3 months ago that suggest this. Plus, all his CAT scans and clinical picture are consistent with this diagnosis. This is not a good diagnosis. The point that he is at right now is such that the cancer has invaded his liver and surrounding structures, causing the liver to fail, which is why he's so yellow. He is, therefore, not a surgical candidate. There are several ways we can go from here. Usually, for this degree of obstruction within the liver, we would perform a procedure where a stent is placed...."
"Usually? What does this mean?" another daughter. "What are you saying?"
[all eyes on me]
"What I'm saying is..."
"What I'm saying ...
"what I'm saying is...
... is that your father's life expectancy is measured in weeks at this point."
[same 3 pairs of eyes]
"I'm sorry"
"There are a lot of aggressive things we could do for his symptoms and condition. But what you have to decide and discuss with him right now, is how much of it is going to be worth the pain in the end."
[eyes]
"I want to go to Florida," says the patient suddenly.
[all eyes turn to him]
Open minded and non judgemental.
"I don't think that's unreasonable," I release into the air.
I leave the room to give them time. I'm covered in hives. I need a drink of water. I'd like to dip myself in water.
I crumple and toss my note from that morning, the one with the 10 step plan. I ask the nurse for discharge paperwork. Someone is leaving the MICU - to go home.
I find the attending. I tell him, I've thought about it. I relay the new plan, the one that includes Florida.
I know SO much aggressive medicine!
Sometimes it SO useless!!
I spend several weeks growing bossiness by way of brutal calls, septic patients, aggressive management, and steep learning curves.
One night, I get called right as I'm fluffing my pillow in the "palace" (the senior resident callroom) at midnight. Apparently, a floor team attempted to manage the hypotensive man all day, but now it has become evident that he would need critical care.
I wake up my intern. We are encountered with an orange orange man. One of the most orange I had ever seen, and I have seen a LOT of orange men, I tell my intern.
His story is, he was diagnosed with a "tumor" over 6 months ago at another hospital. Recommended a workup, and a biopsy, set up with an oncologist. He was discharged and never came back.
3 months ago, again, he was diagnosed at another hospital, this time, with a "likely pancreatic cancer," via some brushings from his biliary system, and again, discharged to follow up with a cancer doc, and never came back.
Now he finally showed up at our hospital, looking like a carrot, and with clear signs of liver failure. Bulging belly, low blood pressure, and, of course, deep jaundice.
I know SO much aggressive medicine. I've been practicing it all year and all month. Plus, this is right up my alley, being a GI case. I know this is not good news. But I know what to do. We'll place a line, work up the hypotension for sepsis, pump some big gun antibiotics, fix the thinned blood with a little vitamin K, consult GI in the morning for placement of stent to relieve his horrendous jaundice. I have a plan.
In the morning, I present the patient to the team. Incidentally, happens to be the same attending as the one who witnessed the Cambodian grieving family with me. I lay out the whole story of how this man tried to evade medical intervention for months and the tragic point to which this had brought him. I propose my carefully thought out 10 step plan of managing his liver failure, biliary obstruction, possible infection, his low blood pressure, coagulopathy, fluids, electrolytes, nutrition, and even prophylaxis.
The attending says....
"WHY?"
"Why... what?"
He says, "Think about it."
I sit down. Post call, I don't participate in the rest of rounds. I have time to think about it. I step back, away from the trees to try to see the proverbial forest. Pancreatic cancer. Orange man. Evading medical management, which, by the way, is useless and painful in this case, for 6 months. I've got him in a MICU bed pinned down, like a mouse in a trap, by the neck with an internal jugular catheter. We're not letting him eat, or drink, and he pees via a catheter.
The family wants to talk to me. I think again about my 10 step plan.
Open posture, open ended question, sympathetic angle of head, don't use the word 'disease'...
"What do you understand so far about the condition...." 3 pairs of eyes.
"Just tell us what's going on!" frustrated daughter.
I sigh.
"By all the information I have so far, your father has what looks like a pancreatic cancer. We don't have a tissue biopsy, which is what we'd need for a definitive diagnosis, but we have brushings from 3 months ago that suggest this. Plus, all his CAT scans and clinical picture are consistent with this diagnosis. This is not a good diagnosis. The point that he is at right now is such that the cancer has invaded his liver and surrounding structures, causing the liver to fail, which is why he's so yellow. He is, therefore, not a surgical candidate. There are several ways we can go from here. Usually, for this degree of obstruction within the liver, we would perform a procedure where a stent is placed...."
"Usually? What does this mean?" another daughter. "What are you saying?"
[all eyes on me]
"What I'm saying is..."
"What I'm saying ...
"what I'm saying is...
... is that your father's life expectancy is measured in weeks at this point."
[same 3 pairs of eyes]
"I'm sorry"
"There are a lot of aggressive things we could do for his symptoms and condition. But what you have to decide and discuss with him right now, is how much of it is going to be worth the pain in the end."
[eyes]
"I want to go to Florida," says the patient suddenly.
[all eyes turn to him]
Open minded and non judgemental.
"I don't think that's unreasonable," I release into the air.
I leave the room to give them time. I'm covered in hives. I need a drink of water. I'd like to dip myself in water.
I crumple and toss my note from that morning, the one with the 10 step plan. I ask the nurse for discharge paperwork. Someone is leaving the MICU - to go home.
I find the attending. I tell him, I've thought about it. I relay the new plan, the one that includes Florida.
I know SO much aggressive medicine!
Sometimes it SO useless!!
Comments
the surgury would have prolonged his life, but it was not a life he wanted to lead...