The Momentum to Do

Austin published a piece with us back in the spring, Room 618. Reading his work brings me back to residency — this case reminded me of a woman I admitted as an in — and I am impressed by his ability to reflect on the meaning of his work while he is in training.

My nights in the medical ICU started the same way. After sign-out from the day team, if I was lucky, I’d have a small window of time before patients got sick and new admissions rolled in. This was a chance to get some much-needed caffeine into my system while I reviewed the day team’s progress on each patient. Unfortunately, coffee doesn’t taste as good at 7 PM as it does at 7 AM.

I spent most of this time reviewing the charts of the patients I had admitted the nights prior. This ritual of review had become one of the highest-yield ways to learn medicine – an opportunity to see where I was right and where I was wrong. My goal was simple: Don’t make the same mistake twice.

My most memorable case had less to do with the art of diagnosis and more to do with the momentum to intervene that permeates medicine.

WM was a healthy 52-year-old female. She presented to an outside hospital with a sore throat for two weeks. Her workup revealed a WBC count of 182,000. She subsequently developed shock and was transferred to our facility.

A diagnosis of acute myeloid leukemia was made with a tentative plan to begin induction chemotherapy. But then came the complications. Each night, at the start of my shift, revealed a new problem: worsening shock, a septic left ankle joint, worsening anemia and thrombocytopenia, renal failure from tumor lysis syndrome, acute hypoxic respiratory failure, severe dysphagia from the pharyngitis, atrial fibrillation with RVR, a STEMI, a subarachnoid hemorrhage, and an acute cerebellar stroke.

Each new problem delayed starting chemotherapy. But the medical machine pushed on. Multiple vasopressors for the shock. Irrigation and drainage of the septic ankle joint. Countless platelet and blood transfusions for the anemia and thrombocytopenia. Continuous renal replacement therapy for the renal failure. Increasing supplemental oxygen support for the respiratory failure. An NG tube for dysphagia. Antiarrhythmic medications for the atrial fibrillation. A stent placed for the myocardial infarction.

It was not until 3 AM on my last shift, six hours after a stroke alert was called, that she asked to just be comfortable. To stop doing more and just focus on treating the pain. Fortunately, despite the new neurological insult, she still had the capacity to ask. When the list of problems had become insurmountable, the path forward revealed itself. That conversation allowed me to see the bigger picture.

As she became sicker and sicker, each intervention maintained the hope of simply starting chemotherapy. Yet the question of what could be expected from the treatment itself remained unanswered. Per her genetic risk stratification, she fell into the adverse NCCN prognosis group. But was it worth it? The default to do didn’t seem to prioritize the answer to that question. The path forward seemed predetermined. A decision to pursue treatment is perfectly acceptable if one’s prognosis and the realistic outcomes of treatment are understood. But what if treatment wasn’t worth it? I write this questioning how we can do a better job of prompting these internal reflections on values and conveying that the option of less is just as valid as the choice to do more. Maybe it’s the stigma around choosing less. Comfort care, especially early on, seems like giving up. Another procedure, another medication, another scan feels like continuing to fight. But choosing less can be just as intentional as choosing more.

Thus far, my residency experience is reflected in the faces of patients and the unique lessons they taught me. WM taught me about the momentum to do that exists in medicine. A few clicks in Epic or a call to a new specialist always seems less burdensome than confronting where all of it is ultimately leading. WM reminds me to resist that momentum and ask the hard questions. To recognize that an alternative path exists. A path of less treatment, less intervention, fewer lines, lab draws, vitals checks, and nights in the hospital.

And maybe, just maybe, more of one’s remaining time spent at home.

Austin Faerber is a PGY-2 in the internal medicine residency at the University of Kentucky. Outside of medicine, he is a triathlete and a lover of endurance sports.

Photo by Sean Musil on Unsplash