I haven't stared at the ceiling in a bit myself. Indigent criminal defense is much like my time as an EMT. I run around like a madwoman, thinking on my feet, making do with whatever was on hand and stabilize, stabilize, stabilize. My clients don't literally die in front of me anymore. They do it slowly, with every new jail term and return to the street from whence they came.
One of my senior residents said to me, “Residency years are like dog years: each one ages you 7 years.” You work so many hours alongside the same people that by the end of residency, you really have had decades of interactions by non-residency relationship measures. You start impressionable and vulnerable and come out as someone who can compartmentalize being part of the literal worst day - or last day - of someone’s life and go microwave your dinner before the second half of your 26 hour day. It forges people who can do the work of medicine but I do wish I could be more of my pre-residency self in my off hours.
My first patient that died occurred as a new fourth yr med student while on a pulmonology rotation. I will never forget, my attending pulled me into the quiet of his room, after the alarms had been turned off and the lights dimmed. She taught me how to diagnose death. And after we were done with the sterile, methodical task, we took a moment to say goodbye.
I focused on the nonchalance of the resident in the dying process. Not judging, just saddened that we can ALL become hardened to others travails and suffering. We probably all have been guilty. Age and years of practice can soften one’s heart and hopefully it will.
I love the idea for this series and am really looking forward to new installments. It's humanizing for patients and practitioners alike to see behind the curtain. Sharing like this would go a long way towards increasing some of the trust lost in the medical profession in recent years; combined with the excellent suggestions for the new CDC director in Dr. Prasad's Substack, the process could truly accelerate.
Thank you for this. I look forward to reading more.
I also remember my first patient death. Also a third-year med student, but in the ER. Older lady came in with abdominal pain, labs looked a little deranged but nothing so bad that they thought she couldn't be seen by the med student first.
Her history? Worsening abdominal pain... and something that sounded suspiciously like coffee ground emesis.
I'd never encountered coffee ground emesis before, so I wasn't sure... how urgent, exactly, is this? I nervously waited to review the case with my staff, and while I waited, the patient asked to use the washroom. She was put on a commode at the bedside, and then, all of a sudden...all hell broke loose. Sudden unconsciousness, drop to the floor, blood and stool everywhere, lifted up onto the bed, starting CPR (first time I'd seen that...), copious emesis (now I *really* know what coffee ground emesis looks like). We "got ROSC" and got her to the scanner, where she lasted long enough to find a massive perforated gastric ulcer. She coded again in the scanner, and that was that.
My training has certainly made me more competent, but perhaps a little *too* efficient. As I finish up my fellowship, I'm looking forward to intentionally returning to the bedside and rediscovering that human connection. After all, if we don't have that, what's the point?
Wow, the part about a patient dying... I think that subject is entirely personal because doctors differ as widely as most professionals. Early in my career, I was training a practice to use their "new computers" and a doctor told me that one of her peers quit within the first year because a patient on his watch passed in front of him. There was nothing on that patient's chart that said he was seriously allergic to penicillin. The young doc never practiced after that. Then there are the very few doctors who fall in the middle. Not the hard-hearted by the book extreme but also not the type that blames themselves after they did everything they could for a patient. I know that my specialists have to review my chart before they see me but once they have, I can tell whether they have any recollection of my case and whether they see me as a human who values my life and still cares for others who also value me. Either they see each patient as an individual who is important in the lives of others or they do not and it is obvious. To your point, either you will be affected by the passing of a patient or you will not. While it should not take over your life, this unique and caring part of your personality will not go away. Only how you respond to it will. (thar ya go, poor English from someone for whom one major was English)
“Sometimes I wonder what would happen if we just let patients who often get narcotics — the chronically ill, those with sickle cell disease — have total control over their own pain medication.”
As a patient and a professional, ALL of us who are prewired for addiction become addicts, especially those of us who love the narcs. Even many who aren’t prewired. I promise you that. I always wondered why many prescribers don’t seem to care about exacerbating addiction in those of us who were child chronic patients. Now THAT is something to learn about in medicine. What I learned about it is that pity has no place in addiction medicine. Or any practice in medicine.
I do not know that we are all pre-wired to be addicted to medicine but we are all pre-disposed to something. With me it would be food but I have gastroparesis so I cannot go out and buy a bag of burgers and fries and a diet soda, as much as I would like to. I eat ridiculously healthy or I pay the price. I have serious chronic pain and at least for me, I do not like the side-effects of pain meds beyond removing the pain. The rest of my life is perfectly imperfect so it is not as if I am content without something to help me feel better. Drugs just make me feel out of control.
I actually wrote that all of us who ARE pre-wired for addiction become addicts - at least in this country. Every addictive substance and behavior is available ad nauseam here in the western culture. I wish you peace within the chronic pain that you have; it’s a very tough row to hoe but it sounds like you’re handling it well!
OK, I understand and I read your comment too quickly. Agreed that every substance has been and I am sure will always be available ad nauseam. Remember Buckley, Jr.'s comments about legalizing drugs? Big, big question. Also am recalling Bobby Jr.'s comment "I was born an addict" in response to whether he used because of the tragedies of his uncle and dad. Thanks very much for the encouragement.
Agree that many are born attached to a bottle! In my understanding we have to have a predisposition AND the exposure to any disease where our behavior can be involved. For example - an African bushman is less likely to become an alcoholic bc the man is likely never to be exposed to excessive amounts of alcohol beyond what the tribe makes in a very weak form. But take that person out of the bush and plop in down in, say, LA and his chance of becoming an alcoholic are the same as anyone living there (about 12-15% of Americans). The chances of diabetes and heart disease would also go sky high. Why? Think of the diet of the bushman in the bush! Roots, yams, what they kill and they are constantly moving. No obesity. I always think of the scene in Dances with Wolves where the American Indian has a taste of sugar and loads his coffee cup! Anyway, you didn’t ask for all that info but it’s a bit of a lazy day for me so here you go!
Thanks for the response. I read it twice and only because I enjoyed it. Happy for you to have had a lazy day! I did too but because I am forced to and am on antibiotics. whine, moan. I don't sit still well. Maybe it is my diet!
Your excellent article brought back some of the whole mix of intense emotions I had as a 3rd yr med student. I can relate to "the idealism of youth, the excitement of possibilities, how deeply you can feel things". And, how the emotional trauma of seeing patients endure terrible suffering beats you up until your skin is thick enough, or not. And, how my clinical teaching was almost entirely from rushed residents, no way to look up drugs except the PDR and so many hours spent struggling to read paper chart notes scribbled down in doctor handwriting. I felt the trauma of seeing how patients desparately relied on a system that seemed almost absurdly fragile. The system was so much better by the time I retired, but I am scared to imagine things that may not have changed and how it is still so often ineffectual for defeating physical and emotional suffering.
I love this series Dr. P. Im just catching up with my inbox. Beautiful writing. ❤️
A good part of our health is luck, some like JP started with bad luck. If you are born with the good luck, appreciate it.
I haven't stared at the ceiling in a bit myself. Indigent criminal defense is much like my time as an EMT. I run around like a madwoman, thinking on my feet, making do with whatever was on hand and stabilize, stabilize, stabilize. My clients don't literally die in front of me anymore. They do it slowly, with every new jail term and return to the street from whence they came.
One of my senior residents said to me, “Residency years are like dog years: each one ages you 7 years.” You work so many hours alongside the same people that by the end of residency, you really have had decades of interactions by non-residency relationship measures. You start impressionable and vulnerable and come out as someone who can compartmentalize being part of the literal worst day - or last day - of someone’s life and go microwave your dinner before the second half of your 26 hour day. It forges people who can do the work of medicine but I do wish I could be more of my pre-residency self in my off hours.
My first patient that died occurred as a new fourth yr med student while on a pulmonology rotation. I will never forget, my attending pulled me into the quiet of his room, after the alarms had been turned off and the lights dimmed. She taught me how to diagnose death. And after we were done with the sterile, methodical task, we took a moment to say goodbye.
Bless your attending. I don't remember my first death but I remember every child death. We all would feel those.
What I learned early on is that many doctors worry more about their patients
than patients worry about themselves.
From my book, ‘I Smuggled Drugs for God’ This story took place in 1969
Complicated Delivery Developed a Mysterious Fever
The mountains in Castañer were very fertile, not only in terms
of tropical plants and fruits, but also for people. Sometimes we
had more deliveries in a day than postpartum beds, so it
became our policy to dismiss patients soon after they had
delivered. After all, before Hospital Castañer was established,
babies in the mountains were born at home without electricity
or running water. It was a major improvement to deliver in a
modern hospital under sterile conditions with doctors and
nurses, then to rest even for a few hours.
One weekend while on call, I delivered eight babies.
One of the mothers was a grand-multip (multiparous - she had
delivered more than eight babies). After delivering a normal
healthy baby girl, this mother's uterus became sluggish and did
not want to clamp down. She began losing large amounts of
blood. I vigorously massaged the uterus and gave her
Methergine intravenously to help stimulate uterine
contractions, which would, I hoped, stop the bleeding. But the
bleeding continued, so I was forced to reach inside the uterus
with instruments to remove pieces of retained placenta, which
were causing the problem. After removing these retained parts
and giving sufficient intravenous fluids, I controlled the
bleeding. She lost well over two pints of blood during this
procedure.
We took the woman to the postpartum room and
carefully watched for continued bleeding. The next day it was
time for her to be discharged. Her bleeding had stopped and her
blood pressure and pulse were normal. I sat with her and
explained how much blood she had lost and, therefore, I
wanted her to go home, stay in bed for a couple of days and
drink lots of fluids. I told her she might feel dizzy or weak and
instructed her to carefully monitor the amount of bleeding. I
urged her to return to the hospital immediately if she soaked
more than one pad an hour. I said I wanted to keep her another
night, but we needed the bed for other women who were in
labor. Late that afternoon I discharged her.
That night I lay awake worrying about this woman. I
had never seen a patient lose so much blood during delivery
and felt that, because she was a grand-multip, she might be
having problems. I imagined her bleeding in her sleep and even
dying. At daybreak I called Bruni, our OB nurse, and told her
we were going to make a house call to visit the patient because
I was worried about her. We got into the hospital Land Rover
and began our long trek up the mountain. She lived only three
miles from the hospital as the crow flies, but it took over 45
minutes to get there by jeep. As we completed the last hairpin
turn up the mountain, I spotted my patient's house way up near
the top.
The house was hanging over the side of the mountain,
precariously built on long stilts with a spectacular view of the
valley. The small, two-room wooden house with its tin roof
was surrounded by dense tropical vegetation and banana and
coffee trees. A variety of fruits and vegetables grew in
clearings below the house. As we got closer, I could see a
woman running up the mountain from one of the garden areas.
It was a steep incline and, from our perspective, it looked as if
she were climbing a sheer wall. When we reached the house,
several of the kids came out to greet us. Joining them were two
typical Puerto Rican dogs, barking excitedly. They looked like
a cross between a hyena and a fox terrier. Chickens scattered
everywhere. The kids invited us to come in. I asked, "How are
your mother and your new baby sister doing?"
They are just fine. Mother's in bed. Would you like to
see her?"
"Yes, I would."
I went into the austere bedroom, made of wood with no
interior finishing. A small wooden window was open to let in
the light. A single bed pushed up against the wall was
apparently where the whole family slept. My patient was lying
in the center of the bed, covered to her neck with a quilt with
only her head peeking out. When I walked over to examine her,
I became alarmed because she was hot and sweaty. It felt as if
she had a fever. She was also breathing rapidly.
I looked at Bruni. "Oh, no. I think she's developed
septic shock and is running a high fever."
But when I tried to pull down the covers to examine her
abdomen, the woman held on tightly. I noticed her hands were
covered with dirt. When I finally pried the covers from her
tightly gripped fists, I discovered she was fully clothed.
Bruni began laughing. "This is the woman we saw
running up the mountain a few minutes ago."
Sure enough, while I lay awake all night worrying about
her, she was contemplating getting up at the crack of dawn to
tend her garden. She was not going to let a birth and a little
blood loss slow her down. When she saw my jeep coming, she
became worried because of my strict instructions to stay in bed.
She knew I would be upset with her. As members of a
paternalistic society, our patients did everything they could to
please us doctors. This patient viewed me as a father figure and
did not want to do anything to displease me. Of course, I was
relieved that her "fever" and labored breathing were the result
of her sprint up the mountain, not from septic shock.
Once the patient knew her charade was over, we all had a great laugh
and she prepared some "cafe con leche" for us before Bruni and
I began the long trip back down to the hospital.
Like me, many doctors worry more about their patients
than some patients worry about themselves. That's the price we
pay for knowing the worst-case scenarios and feeling
responsible for their outcomes.
Great story!
Great addition to Sensible Medicine.
I focused on the nonchalance of the resident in the dying process. Not judging, just saddened that we can ALL become hardened to others travails and suffering. We probably all have been guilty. Age and years of practice can soften one’s heart and hopefully it will.
Thank you for this I look forward to this new series
Thank you for your humanity.
I love the idea for this series and am really looking forward to new installments. It's humanizing for patients and practitioners alike to see behind the curtain. Sharing like this would go a long way towards increasing some of the trust lost in the medical profession in recent years; combined with the excellent suggestions for the new CDC director in Dr. Prasad's Substack, the process could truly accelerate.
Thank you for this. I look forward to reading more.
I also remember my first patient death. Also a third-year med student, but in the ER. Older lady came in with abdominal pain, labs looked a little deranged but nothing so bad that they thought she couldn't be seen by the med student first.
Her history? Worsening abdominal pain... and something that sounded suspiciously like coffee ground emesis.
I'd never encountered coffee ground emesis before, so I wasn't sure... how urgent, exactly, is this? I nervously waited to review the case with my staff, and while I waited, the patient asked to use the washroom. She was put on a commode at the bedside, and then, all of a sudden...all hell broke loose. Sudden unconsciousness, drop to the floor, blood and stool everywhere, lifted up onto the bed, starting CPR (first time I'd seen that...), copious emesis (now I *really* know what coffee ground emesis looks like). We "got ROSC" and got her to the scanner, where she lasted long enough to find a massive perforated gastric ulcer. She coded again in the scanner, and that was that.
My training has certainly made me more competent, but perhaps a little *too* efficient. As I finish up my fellowship, I'm looking forward to intentionally returning to the bedside and rediscovering that human connection. After all, if we don't have that, what's the point?
Wow, the part about a patient dying... I think that subject is entirely personal because doctors differ as widely as most professionals. Early in my career, I was training a practice to use their "new computers" and a doctor told me that one of her peers quit within the first year because a patient on his watch passed in front of him. There was nothing on that patient's chart that said he was seriously allergic to penicillin. The young doc never practiced after that. Then there are the very few doctors who fall in the middle. Not the hard-hearted by the book extreme but also not the type that blames themselves after they did everything they could for a patient. I know that my specialists have to review my chart before they see me but once they have, I can tell whether they have any recollection of my case and whether they see me as a human who values my life and still cares for others who also value me. Either they see each patient as an individual who is important in the lives of others or they do not and it is obvious. To your point, either you will be affected by the passing of a patient or you will not. While it should not take over your life, this unique and caring part of your personality will not go away. Only how you respond to it will. (thar ya go, poor English from someone for whom one major was English)
“Sometimes I wonder what would happen if we just let patients who often get narcotics — the chronically ill, those with sickle cell disease — have total control over their own pain medication.”
As a patient and a professional, ALL of us who are prewired for addiction become addicts, especially those of us who love the narcs. Even many who aren’t prewired. I promise you that. I always wondered why many prescribers don’t seem to care about exacerbating addiction in those of us who were child chronic patients. Now THAT is something to learn about in medicine. What I learned about it is that pity has no place in addiction medicine. Or any practice in medicine.
I do not know that we are all pre-wired to be addicted to medicine but we are all pre-disposed to something. With me it would be food but I have gastroparesis so I cannot go out and buy a bag of burgers and fries and a diet soda, as much as I would like to. I eat ridiculously healthy or I pay the price. I have serious chronic pain and at least for me, I do not like the side-effects of pain meds beyond removing the pain. The rest of my life is perfectly imperfect so it is not as if I am content without something to help me feel better. Drugs just make me feel out of control.
I actually wrote that all of us who ARE pre-wired for addiction become addicts - at least in this country. Every addictive substance and behavior is available ad nauseam here in the western culture. I wish you peace within the chronic pain that you have; it’s a very tough row to hoe but it sounds like you’re handling it well!
OK, I understand and I read your comment too quickly. Agreed that every substance has been and I am sure will always be available ad nauseam. Remember Buckley, Jr.'s comments about legalizing drugs? Big, big question. Also am recalling Bobby Jr.'s comment "I was born an addict" in response to whether he used because of the tragedies of his uncle and dad. Thanks very much for the encouragement.
Agree that many are born attached to a bottle! In my understanding we have to have a predisposition AND the exposure to any disease where our behavior can be involved. For example - an African bushman is less likely to become an alcoholic bc the man is likely never to be exposed to excessive amounts of alcohol beyond what the tribe makes in a very weak form. But take that person out of the bush and plop in down in, say, LA and his chance of becoming an alcoholic are the same as anyone living there (about 12-15% of Americans). The chances of diabetes and heart disease would also go sky high. Why? Think of the diet of the bushman in the bush! Roots, yams, what they kill and they are constantly moving. No obesity. I always think of the scene in Dances with Wolves where the American Indian has a taste of sugar and loads his coffee cup! Anyway, you didn’t ask for all that info but it’s a bit of a lazy day for me so here you go!
Thanks for the response. I read it twice and only because I enjoyed it. Happy for you to have had a lazy day! I did too but because I am forced to and am on antibiotics. whine, moan. I don't sit still well. Maybe it is my diet!
Your excellent article brought back some of the whole mix of intense emotions I had as a 3rd yr med student. I can relate to "the idealism of youth, the excitement of possibilities, how deeply you can feel things". And, how the emotional trauma of seeing patients endure terrible suffering beats you up until your skin is thick enough, or not. And, how my clinical teaching was almost entirely from rushed residents, no way to look up drugs except the PDR and so many hours spent struggling to read paper chart notes scribbled down in doctor handwriting. I felt the trauma of seeing how patients desparately relied on a system that seemed almost absurdly fragile. The system was so much better by the time I retired, but I am scared to imagine things that may not have changed and how it is still so often ineffectual for defeating physical and emotional suffering.
How things do change as one gains more experience, responsibilities, and a functional place in the world.
I've maintained much, and even increased my empathy but the challenges of ethically working within the system are great and the cost is real.