White Coat Notes | Elbrecht's Corpuscle

Death Becomes Us…

Posted on April 6, 2015 by Elbrecht

—–

If everything goes as imagined, my final breaths will be exhaled several decades from now as I look out upon the Atlantic Ocean.

Watching the waves crash upon the shore, I will be alone. By choice. Not wishing anyone I love to see me as a dying corpse, gasping for my last breaths. Hopefully the tide will come crashing in, and, in its return to the ocean, take my body too.

I will have said goodbye to my surviving friends and family while still upright and mobile. Exchanging long embraces, we will depart each others presence to live another day.

My wife, ever accustomed to my eccentric nature, will have laughed, and cried, when the day came for me to leave her, just as I had promised her long before. We will have sat beside our parents, friends, perhaps one of our children, and other loved ones while they succumbed to life’s final crescendo. They not wanting to leave us, and we, not wanting to leave them.

But, Death Becomes Us.

—-

—–

The first time I crushed a man’s ribcage, I was furiously trying to save his lifeless body. As a third year medical student in the ICU, I was tasked with performing chest compressions on a corpse who had, in written certitude, asked for all measures be performed to save his life.

As I felt the brittle bones disintegrate beneath my force, I continued in rhythmic fashion, counting under my breath, and wondering to myself:

“Did anyone see my millisecond of hesitation after the first rib snapped?”

—–

He did not survive. Despite medical science, unwavering will power, the love of everyone in his life, and perhaps a god somewhere in our cosmos, he died like everyone else who had ever lived before him.

He died. Just like I will. Just like you will.

In the three years since that time, I have been present for the deaths of innumerable people. I have lost count.

I don’t believe the number is actually any more than 50, but that’s enough for me to recognize I will die too.

—–

As a physician, I have had the responsibility to pronounce the death of a once-living person. The first time I was called upon to do so, I walked to the patient’s room, and therein, found an elderly woman sitting beside her husband’s dead body, surrounded by her adult children.

The body was already in rigor mortis, laying in the bed, with a crisp white sheet covering the torso, the arms extended beside the chest, and the eyes and mouth closed; forever.

I politely introduced myself to the family, reached my arm out to hold the hand of the widow, and clasped it in my hands for a moment.

I informed the family I would need a moment to examine the body, but they were welcome to stay at the bedside. The widow rose from her seat, looked at her dead husband’s body, and asked to be excused. She stepped behind the room-dividing curtain; one of her daughters joined her.

—–

The diaphragm of my stethoscope was placed over the Aortic region of the chest. My right hand made its way to the left wrist; the pads of my first and second fingers palpated for the radial pulse.

I closed my eyes and listened for a heart beat I knew I wouldn’t find. Simultaneously, my fingers pressed gently, trying to feel a pulse I knew wasn’t there. I moved my stethoscope around on the chest, never once hearing a heart beat or breath.

For completeness, I firmly pressed on the nail bed of a finger, trying to elicit the jerking motion a live man would provide. There was no response. I withdrew my penlight from my left chest pocket, spread the eyelids, and shone the light directly on the pupils. They were fixed and dilated; they did not react at all. I gently released the eyelids.

—-

—–

I respectfully informed the family my examination was complete and provided my condolences.

The widow appeared again and sat back down beside her lost love. I exited the room and proceeded to file my pronouncement of death. I entered a note in the now dead patient’s chart. I called the physician of record to inform he or she of the passing.

In the subsequent months, I have made similar appearances at the bedside, sometimes finding grieving family, other times a vacant room. Each time, the pronouncement was the same.

The time I spent in the ICU as a medical student was easily eclipsed by the four weeks I spent therein as a Resident Physician. Death was only an embolus, cardiac dysarrhythmia, antibiotic-overpowering infection, or apneic respiration away for each person. And on numerous occasions, those life-ending insults occurred simultaneously.

—–

The four weeks of care I provided in the ICU was tempered by the realization that some of it would be futile. A concerned son, seated at the bedside of his father, stopped me one afternoon and asked, “Excuse me doctor, what does it mean if the brain waves are prolonged?” I took a hard look at his father, a man I had never met, who ended up as my patient that morning after a massive heart attack deprived his brain of its needed oxygen, and then looked back at the son, himself a grown man older than I, and took a deep breath.

Nothing I could explain would bring his father back. Nothing we could do in the ICU would change his outcome. We are here for a finite amount of time. And in essence, I explained to a son that his father’s time had come.

I did not feel relieved that I could near-effortlessly explain the basic inner working of the heart, brain, and circulatory system to this man; all of which I had acquired after countless hours of study and dedication. Instead, I felt emboldened to never have someone utter the same nuanced phrases to my own son.

—–

Similar occurrences happened on a daily basis for four weeks. For the fortunate, the family would withdraw the aggressive machinations, which, if prolonged, would have provided a miniscule chance of survival. For the unfortunate, their own wishes (and sometimes their family’s) had been so misguided as to result in aggressive and invasive procedures, which, if successful, would provide only a miniscule chance of survival.

Yet, I know the final minutes, hours, and days provided to the loving members of those patients’ families was beyond worthwhile. To them. To the patient. And to me.

—–

Gray’s Anatomy… continued

Posted on March 21, 2015 by Elbrecht

Gray’s Anatomy… Part I

Other than the hub-bub of “gowning up” every time I needed to see a patient, I enjoyed the four weeks I spent on the Infectious Disease service for a few reasons. First off, our Attendings (the most senior physician who bears most of the underlying responsibility) had been stellar, taking the time and effort to teach us what we needed to recognize as physicians to take care of these growing humans.

Secondly, I enjoyed the day-to-day interaction with the 3rd year medical students who were on our service. I could remember being in their shoes only a few years earlier and had been fortunate to have a few interested Residents teach me how to become a physician. So in like mind, I put forth the effort to interject some critical thinking into their minds during rounds and support their own journey towards becoming a physician.

http://www.youtube.com/watch?v=-OSI-9fo_5o

Yet, after a month of slipping into a yellow contact precaution gown and sliding a droplet precaution mask over my face every time I entered a patient’s room, I was elated to transition to the Hospital Pediatrics service, a mini-Clin Med of sorts.

While I was excited to be on this new service, I was shocked to see the amount of behavioral medical issues that came pouring through the ED. Nearly every night, there would be one or two more suicide attempts, psychotic breakdowns, violent traumas, or kids with simply bizarre behavior admitted on to our service.

Even more concerning, was the existence of a second Resident-run Hospital Pediatrics service, who would also “take on” an equal number of similar admissions each night. The number of admissions became so high that at one point a 3rd service was initiated, run solely by Attendings, only for the behavioral medicine admissions.

—–

There is some messed up stuff going on in this world… And one of the points of identification is the Children’s Hospital Emergency Department.

Thankfully, not all is lost and I cared for many children whose medical problems were cured by antibiotics, hydration, technologic advances, and surgical interventions. The look on a parent’s face when their child has survived a hospitalization is incomparable. The intimate relationship you can build over a few hours with another human being when you are their physician, or even more so their child’s, is at the core of why I chose this for my life.

—–

The next stop on the Internship Train was a month of Obstetrics and Gynecology. As I mentioned in Part I, my six weeks of Ob/Gyn as a student resulted in a two-week “Journey to Reclaim My Soul.” So I must admit, I came into the Ob/Gyn service as a resident with a bit of trepidation.

While I was excited to see the first breath of life for many new babies, when you know you are going to be the one sitting on a stool at the end of a bed as a woman pushes that oxygen-requiring baby towards you, there is a bit of responsibility that comes into play. Even armed with the knowledge that women have been delivering babies for centuries upon centuries with minimal medical intervention, when you are the one charged with helping the baby out of the vagina, it seems like the most monumental task in the history of mankind.

I had been allowed to assist in a couple of deliveries as a student, so I could roughly remember the feeling of a slippery newborn, but nothing prepares you (or specifically, me) to show up on Day 1 and deliver a baby.

But that is exactly what I did. And then again. And again. And again.

Each time it happened during the service was similar, but also dissimilar, to the last. My participation seemed to be the least natural thing I could possibly be doing at that given moment in time. Yet, I would go over and over in my head what I was supposed to be doing: where I should be putting my hands on the vagina, how I should cradle the baby’s head as it popped out, where I should clamp on the umbilical cord, who should I hand the baby to, and on, and on, and on.

—–

—-

Until all of a sudden, the baby was resting on the mother’s stomach, I had delivered the placenta, cleaned the “birthing area”, counted the instruments and gauze pads, and was ready to tear off the sterile gown, gloves, face mask, and booties like Walter White leaving the meth lab.

—–

Upon exiting the birthing suite, I would congratulate the mother and surrounding family again, flash a broad smile, and feel the cortisol levels dropping in my blood stream.

A fitting follow-up to Obstetrics and Gynecology was a four-week vacation on our Surgery Out-patient service. Of course, this wasn’t actually a four-week vacation, but when the hours go from roughly 6A-6PM and 6P-6AM to 8a-5p and there are no screaming babies popping out of vaginas, everything seems like a vacation.

Unlike Ob/Gyn where each day was roughly similar in its expectations, this service was filled with a hodge-podge of different surgical specialties. In the Colo-Rectal surgeon’s office I saw more anuses and hemorrhoids than I would care to admit. On Wednesday mornings the Podiatrist would quiz me on foot X-rays and show me how to wield a scalpel on nasty diabetic foot ulcers. The general surgeon had me poking and prodding at inguinal hernias and draining abscesses.

—–

In order to remind us we were not on vacation, but actually real-life-physicians, I also spent a two weekends that month covering the In-Patient surgical service. In effect, it was the Clin Med for Surgeons: replacing electrolytes, ordering pain medications, changing wound dressings, and evaluating patients for surgical emergencies. Not exactly the exciting life of a Trauma surgeon, but I’ve done worse.

My 7th service found me back on… Clin Med. During our Intern year, we spend two months apiece on Clin Med and OB/Gyn, so making it back to Clin Med represented a half-way point in my year… and gave me the feeling I might actually make it after all.

Gray’s Anatomy

Posted on January 18, 2015 by Elbrecht

—–

The most prominent book on my mantle is Gray’s Anatomy, a text I received from a colleague with whom I worked at Man’s Greatest Hospital. After many hours spent working side-by-side in the Gastrointestinal Cancer Center, she felt it was a fitting gift as I embarked on my mission to becoming a physician.

Nearly six years later, I’m an Intern in a Family Medicine residency program, trying to learn how to become the quintessential doctor.

—–

I spent the first six months of Residency filling many different roles, each of them markedly different from the one before or after. I have been an Internist, Clinician, Gynecologist, Primary Care Provider, Nocturnist, Infectious Disease specialist, Pediatrician, Teacher, Obstetrician, Podiatrist, and Trauma Surgeon. I have also become an even bigger fan of sleep than I ever could have imagined.

The copy of Gray’s Anatomy which I received is a facsimile of the 1901 version, the 15th edition of Henry Gray’s medical masterpiece of the human body. Not much has changed in human biology in the past 113 years, but Gray’s experiences as a physician and lecturer at the Royal College of Surgeons is probably somewhat different from what I experienced in the past six months… or perhaps not.

—–

Day 1 of Residency I was assigned to our Internal Medicine service, responsible for running around the hospital admitting patients, providing them care, discharging them home, all while hoping I’d done a serviceable enough job teaching them about their medical ailment to prevent a hasty return to the Emergency Department.

Of the services we staff as Residents (service = four-week stint as a physician of a specific branch of medicine), Internal Medicine at my Residency is the most labor intensive, sleep-depriving, nerve-wracking, hair-splitting service of them all. The official name is Clinical Medicine, or Clin Med for short (or Clin Dred when you know the next four weeks are about to evaporate into the ether).

—–

Somehow I became one of the two “lucky” lottery winners to be a first-year Resident assigned to Clin Med. My partner was a friend from medical school whom I had known since the beginning. We were paired with two senior Residents, who ostensibly had been the highest functioning first-year Residents on the Clin Med service the previous year and were thus chosen to be our medical mentors.

The ensuing four weeks were so busy that I spoke to my friend for exactly 8 minutes and 11 seconds during the entire month (that includes the time it took to type text messages).

I was told being chosen to start on the Clin Med service should be considered an honor… basically meaning that during my time as a student at the same program the previous year, they had come to the conclusion I would not be responsible for the early demise of any patients who would be placed under my care.

—–

I thought it comparable to being told I would be allowed to be the first person to jump out of an airplane without a
parachute. Low and behold, not a single patient died under my care; or really had any significant downturn in their medical malady.

The days were filled with trying to learn how to navigate the choppy waters of a medical institution and its systems, and the computer programs which allowed me to chart on my patients, along with a physician’s responsibility of percussing my patients’ backs, feeling for pedal pulses, listening to a heart beat while gently pressing along a radial artery, writing perpetually changing orders, and allowing for my own bodily functions to occur when I had a moment.

—–

At the end of the month, I took a deep breath, realized I had survived my first service as a Resident, glanced at the
Gray’s sitting on my mantle, and wondered aloud, “what the hell just happened.”

—–

After a month of learning on the fly about how to be a functional physician in a fast-paced hospital environment, the following two weeks were a nice respite, a smattering of out-patient visits to social service providers in Columbus, office visits by established patients in our out-patient office… and a couple of shifts in the Gyn Clinic.

My experience as a medical student during the six week rotation of Obstetrics and Gynecology were by far the worst of my clinical training. I only survived it by forming a bond with two other colleagues who were equally averse to the responsibilities therein. After that rotation I spent the next two weeks traversing around the Eastern half of the US, visiting old friends, drinking away the memories on an adventure I called “The Journey to Reclaim My Soul.” Sticking a speculum, or even worse, my sterile-gloved fingers, inside women I had met only moments prior wasn’t exactly why I had decided to become a physician.

Stepping foot inside the Gyn clinic was a bit of a flash-back to days of yore. Days I would rather forget. But, I chose to become a Family Medicine physician because I wanted to experience a full-scope of practice, so I needed to use those memories to help the new women I would have asking me about their privates.

—–

In the midst of those two weeks, there were a smattering of half-days in the office, where patients would come to their appointment expecting to see me; not some doctor who happened to be available. They had formally been told I would be their physician. It was a bit of a culture shock unlike what I experienced on the In-Patient service, where people arrived in the hospital hoping for someone with a medical background to cure their ails.

This time, they were expecting “Dr. B.” Whether or not they liked me or thought I was helpful would determine if they would think of me as “Dr. Bullshit” or “Dr. Badass.”

Two short weeks of community clinic visits, office appointments, and speculum insertions were followed by flipping my schedule and going on night-call for two weeks.

It evoked memories of my life for the six months prior to Residency, when I had worked overnight; Except I was traversing the ED, the emotional rollercoaster of my equally sleep-deprived senior Resident, and the perils of septic shocks and intubations at 3am, rather than deciding which return bin to toss some junk into at Amazon.

—–

It had not started smoothly, as my transition back to nocturnal life stymied my brain’s ability to function on the level necessary for a physician. By the end of the second night (by night I mean at 6am, 12 hours into our shift), my senior Resident, 9 years my junior in age, and I had a tit-for-tat critique of each others performance.

—–

And when I say “tit-for-tat” and “each others”, I mean, I got my ass handed to me and had to sit there and take it like a man. By the end of those two weeks though, he and I were having a nice breakfast reminiscing about all the crap we had successfully lived through together.

Gray certainly didn’t write anything about that in his book; I checked.

—–

The first two months of Residency seemed to last forever, but at the same time, it seemed to be over before I knew it. The next two months were spent down the street at the nationally recognized Children’s Hospital, where it is customary for the Interns of my Residency to spend back-to-back months there learning the medical art of Pediatrics.

—–

I was only starting to get the hang of being a Resident by that time, making the transition a bit of a shock to the system as I needed to learn all new faces and an all new electronic medical record; all while assimilating to the hierarchy of a whole new medical specialty.

The Residents of Children’s Hospital learn the ins and outs of treating babies, children, adolescents, teenagers, and the occasional grown adult still suffering from their pediatric medical maladies… I needed to become one of them quickly. The assimilation process when you are a physician is expected to occur over the course of a couple of hours; not a few days or weeks.

So of course I started on the Infectious Disease service right as a never-before experienced scourge affectionately known as “Asthmageddon” swept the Midwest.

—–

Asthmagedden was a region-wide exposure to a newly recognized virus, Enterovirus D68, which was causing babies and children of all ages, with and without previous asthma afflictions, to show up in the Emergency Department in Status Asthmaticus, a diagnosis indicating the inability of the respiratory tract to respond to front-line medical therapy, causing a constant difficulty in breathing.

http://www.wcpo.com/news/health/healthy-living/watch-respiratory-illness-ev-d68-found-in-ohio

Enterovirus typically affects the gastrointestinal tract, causing horrible diarrhea and concomitant dehydration, but as evolution has shown us, a few changes to a gene here or there and all of a sudden a new Enterovirus emerges, now equipped to attack the lower respiratory tract.

Children who had never wheezed, the most common sign of asthma, were having their bronchi inflamed by the virus, making it difficult for air to pass. As somebody who grew up with asthma, I can attest that this is a terrifying feeling.

—–

http://www.youtube.com/watch?v=7EDo9pUYvPE

—–

Some of these children were so sick they were immediately admitted to the Intensive Care Unit to receive the most minute-by-minute care to assure they would not suffocate from a blocked airway. These critically sick children by-passed our normal Infectious Disease unit, but as their symptoms resolved, they would be shuttled to our unit to continue their care alongside the children who were not as severely afflicted.

Of course, a Pediatrics Infectious Disease unit is also full of little tykes with butt abscesses, whooping-cough, diarrheal illnesses, crusty eyes, and non-remitting otitis media (ear infections); and a whole host of anxious parents, who typically become the biggest concern of Residents.

After seeing all of this, I’m re-thinking my plan of having children one day, if at least so I don’t need any psychotropic medications when my kids get sick.

—–

The first three services were a whirlwind of cognitive adventure, psychological daring, and physical extremes. When I hung up my scrubs on the last day of Pediatric Infectious Disease, it was with the knowledge I was only a quarter of the way through Intern Year.

Gray’s Anatomy… continued

Am I Going to Die?

Posted on February 24, 2014 by Elbrecht

[The Death of Socrates, 1787, by Jacques-Louis David]

After only a few instances in the Emergency Department of seeing someone hopped up on meth, crashing from a heroin overdose, or complaining their heart is about to burst from their chest because of cocaine use, most medical care providers quickly lump them all together.

Drug abusers.

To the general public, there are few groups of people more repugnant than drug abusers. The prevailing view is that the damage is largely self-inflicted and the efforts and treatment going towards helping these people is often unwanted and unsuccessful.

—–

Even physicians, who are trained to take every medical situation seriously, get annoyed when drug abusers show up in the ED, clinic, or office.

Those feelings develop because the damage IS self-inflicted. The treatments ARE often unsuccessful. And the efforts CAN be unwanted.

Then why do we go through such great measures to help those who do not want it? Even the medical determination that these individuals have a disease is often brushed aside when a known junkie arrives in the ED for the 20th time in a year.

The reason we go through such great measures is that none of us are truly far from a similar existence.

No.

Even you are not immune to addiction and the perilous spiral your life would become if a moment of weakness crossed paths with an opportune chance.

Some of us are insulated from having weakness and opportunity cross paths by an unrelenting fear of the consequences, from the wrath of the almighty God that would befall us, an emotionally privileged upbringing, or a will that would be unbent by the hottest solar flare.

—–

But a moment of weakness and opportunity is all it takes for the disease of addiction to grab hold and attempt to wrestle your life from you…

—–

The last time I saw Aaron, he was in the Intensive Care Unit (ICU) for the 2nd time in what had now been a five-week hospital stay. Completely unconscious, he was hooked back up to the ventilator and had tubes draining fluid from either side of his chest.

As I approached, adorned in scrubs and nearing the end of a 24-hour shift, the ICU nurse asked, “Is this your patient?” She was patting his head and adjusting his pillow, ever careful to not change the positioning of the tube protruding from his mouth and leading back to the ventilator.

The day before, he and I had spent 20 minutes on our daily pow-wow, talking about how he was feeling and looking. Two weeks earlier, during his first stay in the ICU, I was certain he would be dead by now. But the interceding two weeks had seen him make remarkable improvement. Though he was needing dialysis three times a week, his kidney function was slowly returning to normal, he had begun a liquid diet, and he was able to walk a short distance. His initial presentation, nearly five weeks earlier, had now become a secondary concern.

“No, technically he is not my patient. But I met him the first day he was in the hospital. And, I wish I wasn’t seeing him here again.”

The nurse nodded. All I could do was grasp his right hand and wish I weren’t leaving the hospital in a few hours, unlikely to ever return to his side, whether he lived or died.

http://www.youtube.com/watch?v=jDvIkqapC84

—–

I met Aaron five weeks earlier while on the cardiology consult service. The physician caring for him called asking for guidance on his next course of action. Knowing nothing about Aaron, other than his name and medical record number, I pulled up his file from the safety of computer in a different wing of the hospital. I quickly scrolled through the course of events that brought him to the hospital as well as the events that transpired overnight.

He had been carried into the hospital by his father the previous night, so weak and sick, that he couldn’t do it himself. He had been suffering from periodic fevers and worsening shortness of breath over the past two weeks, but had not wanted to seek out medical care.

—–

Aaron had a long history of heroin abuse, spanning 13 of his 27 years of life, and despite the efforts of his father, and the prospect of leaving his 7 children fatherless, he never could overcome his addiction.

What was found over the course of his work-up in the Emergency Department was not shocking. He had a bacterial infection in his blood, bringing on the fevers, chills, and weakness. He was septic.

Even worse, an echocardiogram of his heart revealed that his shortness of breath was being caused by an accumulation of gunk on one of his heart valves. This gunk was likely a build-up of the same bacteria that was causing him to be septic. It was so thick that blood could not adequately flow through it and become oxygenated in the lungs. {The gunk is more appropriately described as a heart valve “vegetation” and was unquestionably caused by his IV heroin use.}

—–

His story, what had brought him to the ED, was real life emerging from a textbook. Unfortunately, there is no text-book for real life, despite the best efforts of many physicians to describe it; Variables and algorithms go hay-wire outside of the vacuum of medical texts.

By the time I reached his room, he had been notified of his dire situation. He had been told about his vegetation and the need for heart surgery. He was terrified.

I could sense that he was overwhelmed. As he lay there, his facial expression gave away the disappointment in himself. I am certain he wished to be able to get up out of the bed and march out of the hospital under his own power.

Knowing other physicians had already spoken to him, but wanting to give a thorough report to my attending, I decided to start our interaction by asking what he understood about what was going on.

He asked, “Am I going to die?”

The fear visibly swept over him as his lip trembled. His fear jumped off the bed and landed directly on my white coat. My chest tightened as if someone had buttoned the coat a little too tightly.

—–

He began to softly sob. I sat down beside him and offered him my hand. He clutched it with both of his.

His nurse entered the room, saw I was there with him, nodded to me, and turned right back around.

He began collecting himself and his sobbing subsided.

“Why do you think you are going to die?”

In the section of the medical textbooks reserved for instructing future physicians on how to interview patients, I had clearly veered off course. However, such a question turned out to be paramount to uncovering the genesis of Aaron’s own demon.

He revealed that his mother had died during open-heart surgery, 13 years earlier, when he was only a teenager. This information was not lost on me; I had read in his ED notes about the use of heroin since the age of 14.

—–

I would guess suffering such a catastrophic loss must have left him an unmanageable amount of grief. And when the opportunity to leave grief behind and enter a world without it, even if only for the length of a high, he took it… and his own life had begun spiraling out of control since then.

I can not imagine such a level of grief and loss. No amount of reading in a book can prepare you for it or provide you with the skills to overcome it. I believe it is something that can only be understood when you are in the heat of it, facing it, and hoping to not be swept under by it.

—–

Honestly, I am no different from the other medical providers I alluded to earlier. I can become easily annoyed by the behavior and drama arising from drug abusers.

But I’m also careful to quickly remind myself that there is something awful and tragic behind their behavior and drama. Perhaps a situation so dire and all-consuming that I would not be able to resist if a moment of weakness intersected with opportunity.

I don’t know if Aaron is alive or dead.

I hope that the tubes drained the fluid from his chest. I hope they removed the ventilator from his room. I hope his kidneys are working properly again. I hope the surgeon removed the vegetation from his heart. And I hope he is at home, playing with his children, filling the grief that sent him into a downward spiral with the love of his family.

—–

I hope Aaron is alive.