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Monthly Archives: July 2008

With experience comes the wisdom of knowing when to dwell on something and when to move on. It will be a long time before I have that experience or that wisdom. It has been a long time coming, but I finally had the chance today to say good-bye to my first patient: a man in a persistent vegetative state who I began to visit as a junior medical student after the onset of his loss of consciousness. Since he became my patient on my first day on the wards, I have had the joy of seeing several of my patients discharged and sent home, eager to get back to their lives. I have also seen another patient die, despite the best efforts of my team and the other doctors as they fought to preserve the fragile strings holding together his life. Caught between these two extremes is my first patient: unable to leave the hospital through either doorway.

For a student with some early interest in Critical Care, it has been an incredible eye-opening experience to participate in the care of a man who represents the perfect storm: no history, no family, and no advance directive. Here lies a man to whom I did not have the opportunity to introduce myself while he was awake and conscious, and judging from his neurological status, I never will. “The lights may be on, but no one’s home.” It brings to light questions of the nature of personhood and the human soul. What makes a person? What is the lowest common denominator – the minimum requirement, the most basic unit? What gives us a soul, and at what point does that soul depart from the body in the process of dying? From the perspective of a Neurologist and most physicians and scientists, the brain is the final common pathway: without the functional brain, there is no life. Accordingly, we examine patients for the most basic reflexes of the brainstem, the primitive brain, which also carries the patient’s pathways mediating consciousness. Without consciousness, our perception of human life falls apart: there is no response, no communication, and no bidirectional connection to another human being. Humans are, at our core, sociable creatures, and we define ourselves by our ability to relate and interact with one another. If connections cannot be made, does death ensue?

As physicians working with the dying, we dread most the desire of a family for futile care: life support treatment without any significant chance for a return to consciousness. These situations expend resources and the time and effort that might otherwise be spent on other patients, and perhaps more importantly, we wonder whether the patient would want their body perpetuated in a mechanical stasis if there is little or no chance for recovery. Therein lies the dilemma: as healers, we strive with every effort toward preserving life, and yet we sometimes find ourselves in the position of wishing a peaceful passing for dying patients in opposition to our instinct and imperative to intervene. Some people abhor our current life-preserving technologies for producing these expensive, ethically disturbing, and emotionally challenging situations, but they lack the perspective of the tragedy of the many lives lost that otherwise might be saved. How do we judge the quality of human life? Should we abstain from treating children with cancer because we know that our treatments may give them severe chronic diseases if they survive to adulthood? If we had taken this defeatist attitude with HIV/AIDS, how could we have possibly succeeded in making it possible to live a normal, mostly unfettered life span taking only a single pill a day? Our science and treatment is imperfect. Imperfection produces side effects, but we have to do the best we can with what we have until we can create something better. For now, that is why we hope patients will have advance directives, living wills, powers of attorney, or at least a clear, communicated idea of what they would wish for.

Until that day or until I face these issues as a physician, all I can do is take one minute out of the day to grasp a man’s hand and say: “I will no longer be checking in on you as one of my patients, but nevertheless, sir, it has been my honor caring for you. I hope you find your way home.”

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The specter of death is not a comforting companion. In confronting the possibility, I have seen friends and colleagues find it natural to be overwhelmed with aversion to the insistence of mortality or sadness, especially when our normally capable minds and bodies are rendered helpless by the lack of time and opportunity to intervene. Others feel their emotions are blunted by the relentless arrival of tragedy at the doorsteps of our hospitals, or they find reasonable (but not insensitive) methods of coping with the mental stress of a patient’s impending death through humor or simply moving on. Today, on my first day of my Neurology clerkship and the first day on the wards as a member of a medical team expected to function with a small but significant degree of independence, I found that the only time I did not feel overwhelmed by the changes around me was during the times I watched a comatose patient and as my team discussed his case and the unfortunate likelihood that he would not wake up again. I was surprised by the incredible calm I felt in my mind and soul: I did not feel averse to the scene and situation, nor did I find myself overwhelmed by sadness. Being in the presence of unconscious patients neither excites nor comforts me, as I love speaking with and developing therapeutic relationships with patients. I did feel sad for the patient, but it was a sadness that elicited a moment of clarity: I wanted to be there to watch over him and see him through this perilous journey. He may never know my name or see my face, but yet I still felt that I can offer him something, however small or fragile. By chance or through some insight on the part of my senior resident, I have since been assigned to his case, as complex as it might be for a green third year medical student.

However, in most other situations today I felt startlingly incapable: seeing my residents and senior student explore and present their cases impressed upon me the great distance I will have to travel to achieve their degrees of functionality, expertise, and poise. This is not to say there is nothing I can do now: I answered my first “pimping” question involving MRI interpretation from the attending physician correctly, and one of my elderly patients in the clinic told me “I’m sad you’re not going to be my doctor because I’ve fallen in love with you” (e.g. as a clinician, and the rapport we were able to develop in a short amount of time in managing her neurological condition). Nevertheless, when I see the residents on my team perform so effectively and efficiently, my psychological response is very different from when I have followed an excellent physician in the past: instead of wistfully thinking “I hope I can be as good a doctor one day,” today I thought, “Now I actually see the path to becoming what I want to be, and it’s a lot harder than I might have originally expected.” This is an admission of arrogance on my part, and one shared by other medical students who corroborate this feeling: in so many areas of academic performance we have found ourselves at ease, but entering the workplace in a career such as medicine involves a much higher order of complexity in the union of scientific knowledge, interpersonal skills (communication, diplomacy, language, social awareness, etc.), experiential wisdom and insight, and personal fortitude against the countless stressors, unexpected twists, and tragedies. Here we stand with our toes barely touching the bottom of the sea floor before a tremendous drop into the ocean depths: depths that are barely visible from where we currently stand at the beginning of third year and which are almost completely invisible to someone standing at the shore.

I find it very unusual that I might find my only time of calm and clarity on this first day in the moment of greatest sadness, fury, and disappointment. Is this a return to a personal primordial concept of what a hospital should be, as my earliest experiences with inpatient care involved sitting by the bedside of a comatose woman during the two weeks prior to her death? Or I wonder if perhaps being in the presence of an unconscious patient strips away my anxiety and inappropriate self-expectations that my worrisome mind imagines are mirrored in the faces of other patients and my team. Our attending physician and senior resident have specified what at first glance may seem like easy or simple objectives: first, to learn to perform a complete and ordered neurological examination; second, to be able to localize lesions in the neurological axis; and third, to be able to present and write-up our patients effectively. These are at once small and massive tasks, and I have to balance telling myself that I will not be able to master these skills on the first day of my rotation and my third year (indeed, I may never truly master them) and telling myself that I want to be better than expected. Whose expectations? With the expectations of the attending physician and the senior resident firmly based in the reality of training and medicine and my expectations extrapolated from prior knowledge of self and ability, it is clear that I will be getting to know myself a lot better during this next year of my life, my training, and my path.

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