Life Lessons

A recent post that has been edited and recently accepted for publication in The Human Touch, a literary publication by the University of Colorado School of Medicine. 

These are the parts of family medicine that I adore: the pink cheeks of a 3 year old I want to squeeze so badly I have to nearly restrain myself; a baby that isn’t mine I so desire to cradle; an old man with broken bones who still cries for the love he lost years ago. His advice to age gracefully is to pray for luck and patience. He says living to 96 years old has very little to do with humor, then chuckles.

There are the pauses in a story while a patient decides what to tell me...knowing I can tell even more from their silence sometimes. In this space is a soft whoosh of blood in an artery, the stammering persistence of an imperfect heart, a lymph node swollen like a speed bump to recovery. Here, there is pain. And patience. And salvation.

As PA students we are taught to think of common ailments and keep our differentials broad. A numb hand, to me, looks a lot like a pinched nerve, neuropathy, inflammation from micro trauma, carpal tunnel, or perhaps even something psychosomatic. Most of the differentials aren’t life threatening.

So when the woman arrived with the numb hand and foot, she didn’t “impress” me. Non-impressive ailments, I’ve been told, are good—it means they are probably benign. She was 47 years old, appeared in good health, but had been vomiting for days, the result of food poisoning, she thought. Then today she woke up with the numbness—“Like I fell asleep on my hand and foot and they are now waking up.” Almost as an afterthought, she mentioned some intermittent stabbing chest pain. As she described the chest pain to me she assumed Levine’s sign. My pulse quickened. “It’s the heart,” I thought, “her electrolytes are out of whack and she’s had an MI.”

Now I was impressed, especially when she began to describe a disconnect between her brain and her right hand. Just that morning she had difficulty putting her coat on, putting the key in the ignition, typing on her computer. Her right hand wouldn’t “behave,” she said, nervously, “like it had a mind of its own.”

Could it be a pinched nerve with some level of cognitive decline? An MI that was affecting perfusion to the limbs? I ordered an EKG, but it was clean. My preceptor, who now also looked worried, quizzed me: “What in the body could do that? Cause only one side—her right side—to be affected?” And it dawned on me, like so many subtleties of medicine do, that there is only one thing that could affect the body in that way: the brain.

I whispered her most likely diagnosis: A vaguely symptomatic cerebral infarction. In other words, a stroke. 

I was immediately thrilled with the finding, bearing witness to the symptoms manifesting before my eyes. And, moments later, I felt the heartbreak as my patient’s face crumbled, as I beheld fear in the eyes of another human being (probably mirroring the fear in my own) because we both finally realized that something was terribly wrong.

She was hospitalized that day with an acute cerebral infarction, at a young age, with no risk factors. It could happen to any of us. But when will it happen? And where? And, maybe even more importantly, why?

The day rambled on, as they all do. I diagnosed URI’s, asthma, performed physical exams through the afternoon, but I continued to think about that woman. In between the coughs and colds, the lumps and bumps, linger these extraordinary and humbling moments that are propelling me into the most challenging endeavor I have ever undertaken. Aside from the textbooks, endless studying, faculty guidance and exams, lie the most phenomenal teachers of all: the patients.

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Code Blue

This piece, in a slightly edited version, was recently featured on the AAPA website - American Academy of Physician Assistants. 

The man in bed #9 told his nurse that he was going to die. He felt "impending doom" and didn't want his family called to his bedside. In fact, he just called the nurse in the room because he thought he was going to die and wanted to tell someone. 

Less than one hour later, it happened. 

My first code blue.

In a hospital setting, when a patient "codes" it usually means the patient is in need of resuscitation from respiratory or cardiac failure. Any medical professional may respond to a code, but generally those responders should be trained in advanced cardiac life support (ACLS), which I am. These "ACLS teams" are made up of physicians who "run the codes" and anesthesiologists, internal medicine docs, respiratory therapists, pharmacists and nurses. And, in this case, me. 

I didn't know what to expect as I ran down the hall after hearing "code blue" over the intercom. I knew that I should go, because I could help. But I was also well aware that I had never participated in a code.

When I got to the room I saw a man vomiting up a great deal of stomach contents and then inadvertently swallowing them back down into his lungs—a severe aspiration and very, very bad. He was in acute respiratory failure. The oxygen saturation of his blood was dropping. His heart had an unstable rhythm. Then, with nearly no notice at all, he collapsed, his heartbeat a calm flat line. Right then and there, quite simply, he died. 

We had roughly 20 minutes to get him back. 

I began chest compressions. I was terrified, exhilarated. Adrenaline was turning my ears hot, my body an immediate sheen of sweat. I’ve never felt such tangible energy in a room as others began arriving—ER docs, nurses, other critical support staff, pharmacists and relief CPR staff (a person is only allowed 2 minutes of deep, fast and even chest compressions before relief—you would be amazed how exhausting 2 minutes of sustained compressions can be!).

What I didn’t expect

As a first-time code participant, and PA student, these were the things I didn't expect:

·      I wasn't prepared for the sound of the ribs breaking in the man's chest. It sounded like stepping on stiff dry twigs in the park. Deep chest compressions are required to "squish" the heart in a person's chest hard enough so that the heart continues to somewhat "beat" and move blood around the body. To compress that hard, you break bones. Chest compressions are critical. Mortality (death) and morbidity (co-occurring medical conditions) are significantly reduced when chest compressions are begun immediately and sustained. The longer the team can sustain blood "squishing" around the body, the more time it has to literally work magic and bring the patient back. 

·      Time stops during a code. During the time I was in that room I swear I only took a handful of breaths. I could have been anywhere in the world, doing anything: watching a show, napping, preparing dinner, taking a walk, daydreaming. But instead I was in that room, with that man's heart and broken ribs below my hands, and compressing like hell with both forearms on fire. 

·      They say that people who are about to die know when their end is near. They can sense it. They feel it. Patients who have come back from the brink of their own death tell me that this feeling is an enormous awareness and nearly inescapable. And while I never had a chance to speak to this patient in particular,  his nurse told me he said the very exact thing.  

·      The heart is somewhat scandalous and completely unpredictable.  During the code, the patient's heart experienced multiple difficult arrhythmias that could easily lead to death, including ventricular fibrillation (where the heart resembles a “bag of worms” and does not contract properly), asystole (flat line), pulseless electrical activity, ventricular tachycardia (a fast and dangerous rhythm where the ventricles may become unable to adequately fill back up with blood), Torsades de pointes (literally, a “twisting of points” and an uncommon variant of ventricular tachycardia, resulting in lengthening of the QT interval), complete heart block, back to ventricular tachycardia and then, finally, the pharmacists were able to externally pace his heart—essentially triggering the muscle to beat at an electrically sustained interval. 

·      Watching a human being die is one of the most memorable, strangest, fascinating and incomprehensible experiences I have ever encountered. The patient died several times while I was in the room with those 15 other healthcare providers. And I have no doubt he was out there somewhere—in the great beyond, the Divine Mystery—floating around, maybe happily disconnected from his ill and failing body and considering his own next bold move. 

·      The more chaotic the situation, the calmer I felt. And I sensed the other providers in the room felt the same. In the seriousness of the situation, there was even a bit of humor to ease the overall tension. I was elbow to elbow with trained professionals, and I was proud. The ultimate goal is to respect that something is happening, something very much beyond our control. After all, death is as natural to our existence as breathing. Still, the idea of death is uncomfortable, even on the critical ward of a hospital. As Jimi Hendrix put it, "Life is pleasant. Death is peaceful. It's the transition that's troublesome." 

·      As a student, you want to be in on the action during a code, especially if it’s your first. The key is to stay out of the way until you are needed. A student’s best shot to participate is to get in the CPR line and wait for your turn to fire off 2 minutes of the best chest compressions of your life. After that, tuck into the wall somewhere, make yourself small, do what you can to stay in the room but out of the way, and be at the ready should they need you again. In the meantime, you will learn ACLS better than any textbook or mock code will teach you.

Aftermath

I stood back once my contribution was over and took it all in. I pressed myself against the wall and stayed out of the way. I mentally checked off the protocol in place—the scheduled dose of atropine, dopamine, epinephrine...the shock and CLEAR of the paddles.

Twenty-two turns of the hands of the clock occurred while time was stopped.

During those 22 minutes the patient was gone from this earth.

One minute before, at 21 minutes, the physician was ready to call the code.

But he didn't. And at 23 minutes the patient came out of his many dysrhythmias and stabilized.

Alive. Like the rest of us. For one more day. 

In Patience

I am now two days into my internal medicine rotation and I am feeling somewhat unsettled. My surgery rotation, thankfully, taught me more about internal medicine than I'd thought and I arrived yesterday (Monday) spry, excited, and ready to go.

That was, until I met my first patient...

A bit of history: I became interested in Palliative Care about 5 years ago while living in Denver, CO. While doing research at the University of Colorado, I discovered that, on Christmas Eve, 12 patients died at the University Hospital. Now, I realize that people die every day and I'm not such a bleeding heart to deny that death is a natural part of each of us existing on this planet and experiencing life. But, what caught my attention was one glaring detail: Each of these patients had a terminal injury or illness--a car accident, progressive neurological disease, aggressive cancer. And, each of these patients died in their hospital room. In the middle of the night. Alone.

Palliative care is NOT end of life care. It is not hospice, although hospice is part of it. Palliative care doesn't focus on comfort care and end of life issues as much as it focuses on the individual and every aspect of their healing--spiritual, psychological, emotional, and social. Palliative care applies to any individual with an acute or chronic medical condition that doesnt necessarily have to be terminal (ie a young person with liver failure, someone with leukemia, a cancer patient exhausted and unwilling to continue with chemotherapy). It is designed to alleviate a patient's suffering while also acknowledging and enhancing the patient's quality of life.

I greatly appreciate palliative care because it doesn't just focus on the physical part of healing and pain: which we have pain meds for. When we are sick we are suffering, on so many levels that a lab slip will never pick up. I think about those 12 patients dying alone on Christmas eve--one person's family was too far away and he was in a motor vehicle accident and would die within hours, another man was estranged from his family and none of them knew he was hospitalized, yet another patient, simply, had no one.

Soon after this happened, I volunteered at the hospital to help set up a palliative care volunteer system, mostly made up of retired nurses. If a patient was on the floors and was very sick, or terminally ill, or just plain lonely, one of these "volunteers" would be available to sit with him or her, read books, watch movies, talk, cry, essentially be present.  It was a powerful offering and experience for the patients and the volunteers. And it was necessary. One of the best indicators of good health, and healing, is social support and human interaction.

It's kind of amazing that now, years later, I'm here not as a palliative care volunteer in internal medicine, but on the other side, as a consultant, a medical professional in training, a woman in a white coat faced with a plethora of pleading eyes asking me at nearly every turn--How am I? Can I go home? Will I get better? Will you help me? I have very few answers because most of the time I'm scrambling to fulfill lab orders, or follow up on a newly admitted patient, or follow up on a current patient that has just taken a turn for the worse, or--sometimes, but not often enough--get paperwork ready to discharge a patient home because they are on the mend!

But I have limits after all, because internal medicine breaks my heart in a way that nothing else ever has. It breaks my heart with its exquisite suffering...AND its insufferable hope. I vacillate all day between hope for a particular patient and his or her family, and despair. This roller coaster is exhausting, exactly like it is for the patients.

So I try to focus on the medicine, but its difficult with ill people, who are extraordinary and unique in their own right, wishing to impart a life's worth of advice in the few moments I have with them.

Advice from my patients today:

"Listen to the person who is talking to you. If you don't agree, that is okay. We all have an opinion. But don't forget to listen."

"Don't argue. I have never believed in arguing."

"It's true, laughter is the best medicine."

"My parents raised me on nothing but love and kindness."

"I may be sick and dying, but I have several beautiful sons and daughters and am rich beyond measure."

"I hope I get out of here for one more beer. You don't appreciate a good beer until you realize you can't have one whenever you want."

Tomorrow I will sit in on two palliative care consultations--for patients who no longer want to subject their bodies to harsh medical treatments for their conditions. I get that. And I get that they are not giving up by making such a decision. What I don't get is that we live in a society that allows people to die on Christmas Eve, and every day of the year, alone.

I'm going to go grab a beer now, and tell a few people I love them, and listen to the soft patter of the rain and the wind rustling outside. Because I have the time. And because this life is so goddamn amazing.

Colorado Healing

There are places I go to heal. These places are usually out of reach for most of humanity; they are  hidden, sacred. They take more than expendable energy to get to. Trekking to them may elicit a bit of blood, sweat and sometimes even tears. These places remind me how grand the world is, how much beauty a spacious vista can hold, and they also provide a certain amount of affection that a lover never can.

Even though I was physically born in Wisconsin, I was "born" in Colorado. The first time I laid eyes on the Rocky Mountains while driving along I-70 with my uncles I was awestruck. The expansive view through the windshield near Lookout Mountain was one I had dreamt of for years, since I was a small girl watching Swiss Family Robinson, or Little House on the Prairie, or any of a handful of other rural/mountainesqe type TV shows. Even at 18 years old I knew I would move to Colorado the first chance I could. And I did.

Now, the North Cascades of Washington are fulfilling the role that the Rocky Mountains did when I was living in Fort Collins and Denver, CO. These are now the mountains I drive towards when I need to get back to who I am.

When I think of mountain healing, I think of Sue Fear, a mountaineer I met years ago on a plane from Tasmania to Sydney, Australia. Sue was a striking woman in her 40's, drinking a beer in the airport --which was allowed -- but the beer she was drinking they didn't sell there. So, she was escorted outside of the terminal until our flight boarded. I thought it was a bit silly that the Tasmanians, in all their kind heartedness, would be so strict with beer, but there it was. I went outside and gave her one of my beers, which they also didn't sell at the airport. It was over the next hour that I began to realize who she was.

Sue Fear, in 2001, became the first Australian woman to summit Mount Everest. And here I was, an American mountain lover, looking into the blue depth of this woman's eyes and trying to imagine all the glorious glacial beauty she had beholden. She told me she went to the mountains to live, and went back home, to Sydney, only when she was drained. At home, her nest, she filled her reservoir back up - her hopes, her desires - and once it was full again, she went back out into the world to tackle another high peak. We stayed in touch and she sent me a copy of her book, Fear No Boundary. I was back in Australia and trying to track her down to meet up for dinner when I heard, through a friend of a friend, that she had fallen through a crevasse on K2 a week prior. Her body was never recovered.

I think of her today, because the mountains are where I go to heal. Where I personally go to BOTH fill and empty my reservoir.

After the last month in my surgery rotation, I didn't realize how much I needed a bit of healing until I said goodbye to that last patient on that last day. And what resonated about that final meeting was that that patient was going home to die. And the mountains were also a place of healing for her. She would never get to hike in them again. I told her I would take her with me next time I went.

So, my question is: Where do you go? What heals you? This is something I want to think about, and respect, as I move forward through this next week "off" from school and patients, because one week from today I begin again, and my next rotation is in Internal Medicine. I am most excited for this next rotation because I am ready for it. And I want to remember that the patients are more than medical enigmas, more than bodies in a bed. They are humans with memories, and places and favorite spots to have picnics or to watch the sunset. They are people with mountains, in every sense of the metaphor imaginable.

As medical providers I believe we can offer more than we think we can. Sure, we can provide diagnoses (hopefully sooner than later) of complicated medical conditions, we can provide comfort care. But we can also acknowledge and nurture the emotional and spiritual lives of our patients--some of which are most important in the healing process. 

So, this week I am healing. In some of my favorite places.

Ask me sometime, and I will take you there.