Where Trauma Meets Tragedy

“Full Trauma Now.” The words blare across the emergency department. There is a rush towards the trauma bay – stretchers, x-ray technicians, nurses, medical students, residents, attending physicians. We dress in our protective gear – plastic blue gowns, gray gloves, face masks, blue marshmallow hats. And we wait. “Have you heard the story?” One nurse whispers to another.

“It sounds bad…car vs. tree, I think, or maybe bike vs. tree, I’m not exactly sure…” She tilts her head up, as if trying to grasp the story from thin air.

One of the technicians pipes up, “GCS 4 in the field. Not intubated.”

A nearby resident raises an eyebrow, “Really? They haven’t intubated yet?” He gets his equipment ready – suction, tube, blade. Everything is in order.

And we wait.

Minutes go by.

A nervous, hushed wave of conversation ripples across the room. The hum of stretcher wheels fast approaches, or perhaps we are only imagining it. The air is thick with anticipation.

This is the trauma bay. The small, rectangular room where life meets death. But I have rarely seen a death here. Because we have become so skilled at keeping people alive, we are often able to stabilize patients for just enough time to whisk them away to the operating room or the intensive care unit. Even so, this is the room where a sudden life change is first realized, observed, and recorded. This is where it all begins. A bay – it is not a fitting term, really. Bright red airway bags, big computer screens, beeping monitors, life-saving carts, stretchers, fluorescent lighting. And there is no peace here. It is not a bay – more of an ocean, with unseen waves, trade winds, thunder, lightning strikes.

I have watched many patients meet their fate here. And yesterday, for one, the tears welled up. I know exactly how to hold them back – have become an expert, in fact, at letting them come just far enough to the brim of my lashes, so that if I smile it almost looks as though they are a twinkle and not a tear. Have I begun to feel again, after these years of blocking everything out? Perhaps. I was pleased to discover them – quite unexpected, I might add. Incredible that after all this time the tear ducts still function in the old, familiar way. A miracle, really.

As I watch this woman’s tragedy unfold in front of my eyes, I realize that she will not make it. I look at her, I look at the CT scan, and I know – with certainty. I no longer have the naïve hope of a medical student. I no longer need to look to my attending for confirmation. I almost wish I did. I glimpse the family at her bedside. Children, grandchildren, sister. I watch them weep. Their eyes are wide – too much hope, I think. I want to brace them for what lies ahead. But I know that would be impossible. A shock is not absorbed, or even felt, at first. It just is. It glares you in the face.

This is my last day as a second year resident. How the time has gone by. How much has changed. Children, grandchildren, sister. I watch them weep. And for a moment, I let myself remember what it feels like to be one of them. I, in my white coat, with too much knowledge for my own good. I, the doctor. No more or less powerful than they are, when it comes down to it. I put myself in their shoes. Slip them on my feet, feel the worn leather, tap them on the white floors, now splattered with blood. I watch them weep. And I feel something – not as much for her, but for them. For all the trials they will face in the coming hours, for all the tears they will shed, for their loss.

They loved her so much, didn’t they?

White Coats: Can We or Should We Learn Compassion?

An article written by Dr. Sally Satel in The Wall Street Journal today, Physician, Humanize Thyself, discusses the origins of the white coat ceremony. In the 1980s, as insurance companies placed increasing pressure on physicians to minimize visit time and maximize patient volume, the medical profession at large became increasingly cynical and disgruntled. A direct result of this was the White Coat Ceremony, whereby each medical student goes up on stage to receive his or her first white coat in front of physicians, classmates, and family. Many US medical schools initiated this movement in the 1980s in an attempt to remind the emerging physicians of the importance of their role as compassionate, empathetic healers.

Does the ceremony work to encourage compassion? The short answer is no. It represents a ceremonial celebration for medical students as they move forward in their careers and enter the patient care setting for the first time. It represents a time when colleagues, faculty, and families come together to celebrate the achievements of medical students. But if we believe that, at times of frustration in the hospital, medical students will look back on this white coat ceremony and remember compassion, we are far too idealistic. I agree with Dr. Judah Goldberg, who is quoted in the article as saying, “To the extent that empathy can be taught through a ritual, a hospital gown, the common garb of human frailty, would be more fitting than a distancing white coat.” He is absolutely right: the single best way to get medical students to think about illness in a compassionate way is to put them in a hospital gown. Haines had the right idea in the film The Doctor, a story about surgeon Dr. Jack (William Hurt) who, after being diagnosed with throat cancer, is forced to view medical care from the “other” side. At the end of the film, Jack instructs all of his interns to put on gowns: they are to be patients in the hospital for the next 24 hours. Blood draws, hospital food, physical exams – they are going to experience it all, hospital life in full, from the disempowered and vulnerable viewpoint of the patient.

Still of William Hurt and Charlie Korsmo in The Doctor

In my experience, routine visits to the hospital or doctor’s office remind me what it feels like to be a patient. In general, the feeling is not good. I find that I am much more attentive to my patients’ needs after a visit like this, when my memory of my own experience remains vivid and fresh in my mind. Compassion is an important part of the physician-patient relationship. How do we achieve this? We need to listen, to comfort, and to respond to our patients’ needs. We need to care for our patients rather than their illnesses. We need to envision our patients as people and not as a laundry list of medical conditions. This last task, perhaps the most important, is also the most difficult. When we care for people day in and day out who are dressed in hospital gowns and are not feeling well, it becomes too easy for us to forget that these patients are individuals who have a full life outside of the hospital – a life about which we know very little.

A new trend in medicine is to admit students who have a degree in liberal arts. Satel mentions that some schools, like Mount Sinai School of Medicine, even admit students who have not taken some of the requisite science courses or the MCAT. Students who majored in the humanities can certainly bring a different perspective to medicine. But there is no guarantee that we are admitting students who will become compassionate physicians. Why not?

1. We cannot predict how medical students will change during their careers. It is widely acknowledged that physicians become increasingly cynical as they move forward in their careers. This cynicism is particularly evident in a field like emergency medicine, where physicians often become frustrated with caring for patients who are not linked in to our health care system. Many do not have health insurance or a primary care provider, and thus cannot follow-up appropriately. Some roam from emergency department to emergency department looking for pain medication or some inadequate, less expensive substitute for longitudinal care.

2. We cannot necessarily change someone’s inherent personality, nor can we discover it through the medical school application process. Even if we argue that certain people are inherently compassionate and that these are the people who should be trained for the job, we cannot necessarily judge which applicant is more compassionate than the next based on the limited information in a medical school application. One could argue that students on the pre-med track are inherently selfish, at least to some degree. They have many requirements to fulfill and spend much of their time in college achieving – in the classroom, in the research lab, and in their volunteer activities. Just because someone has a long list of “compassionate” activities on a résumé does not prove that they are truly compassionate. And even if they are, the argument becomes circular when we return to number 1 above.

3. The last point, and this one has more speculation involved, is that perhaps compassion is not the most important quality for a doctor. Doctors need to strike a balance between distance and intimacy. To disregard all physician-patients boundaries would likely make patients feel uncomfortable and physicians feel emotionally drained. Already, the statistics on physician well-being are not reassuring. Depression is at least as common in the medical profession as in the general population, affecting about 12% of men and 18% of women. Depression rates are higher for medical students and residents, with 15-30% screening positive for depressive symptoms. All of these numbers are likely lower than the real percentages due to under-reporting (there is significant stigma among medical professionals about psychiatric illness). After accidents, suicide is the most common cause of death among medical students. Suicide rates are higher among physicians, 28 to 40 per 100,000, than in the general population, 12.3 per 100,000 (Council on Scientific Affairs: Results and implications of the AMA-APA Physician Mortality Project, Stage II. JAMA 1987; 257:2949-2953). This is partly due to the higher success rates of suicide attempts. This data is from an eMedicine article written by Dr. Louise Andrew, entitled Physician Suicide. A perspective article by Schernhammer in The New England Journal of MedicineTaking Their Own Lives — The High Rate of Physician Suicide, discusses some of the problems which lead to physician suicide.

Ultimately, the successful physician finds a balance between compassion and emotional distance, and he is thus able to continue his practice and live happily. But this is easier said than done, especially for physicians who are struggling through their years in residency. Perhaps a lack of compassion is our own survival mechanism.

The issue of compassion is much more complex than it seems. And I have only addressed the physician side of things – the patient side adds an entirely new dimension to the dilemma. Patients have different preferences about the degree and nature of compassion which they expect to receive from physicians. Compassion is undoubtedly an important aspect of the physician-patient relationship, but how important and in what ways is somewhat controversial. Furthermore, if a physician acts compassionately towards his patients without feeling compassionate, is this sufficient? Perhaps the act alone will suffice, if it is performed well. But to disregard compassion completely, to treat our patients as Dr. Jack initially did in the film, would be to fail as a physician and healer and to disregard a critical part of the physician’s calling.

Dawn to the Moon

Today began at the break of dawn and ended with the moon outside my window. I can hardly believe I am saying this – I miss the coronary care unit. The emergency department is a flurry. Placing too much emphasis on patient flow does not always mean providing the best care. I miss talking to my patients, listening to their stories, caring for them, and answering their questions. I can hardly estimate the number of patients whom I cared for today or remember them – 5 or 6 were flooding through the doors every hour.

A wonderful article was published today in The New York Times yesterday, Palliative Care Extends Life of Lung Cancer Patients, Study Finds. A study in the New England Journal of Medicine has demonstrated that patients with terminal lung cancer were happier, more mobile, in less pain – and they lived nearly three months longer. This study supports some of the thoughts I discussed from Gawande’s recent article in a previous post, The End of Life: Hope Without Cure. It offers proof that the purpose of palliative care is more than simply “to palliate” – it can also improve quality of life and can even extend life. Palliative care, along with alternative medical therapies including acupuncture and massage, can be important adjuncts to medical care. This needs to be further examined in the science-based health care system of the western world. More on this later.

For now, as the clouds begin to obscure the moonlight, I breathe – long and deep – to expel the chaos of the day. Working in the emergency department is draining in a different kind of way – fast-paced, high energy, elevated stress levels. It is not as much a marathon but a series of very long sprints.

The End of Life: Hope Without Cure

Winter Snowdrops

Atul Gawande’s beautifully written article in the New Yorker this past week, Letting Go, tells poignant stories of young men and women coping with end-of-life issues in the American health care system. One of the greatest obstacles to achieving a “meaningful death” in America is that this concept is not integrated into our culture. Survival, cure, prolongation of life – we do these things very well. But when it comes time to contemplate the dying process, we are often overcome by fear, uncertainty, and worst of all – denial.

Historically and culturally, people have dealt with the dying process and with letting go in a variety of ways. Nomadic tribes often left the elderly behind to die alone – they were sacrificed for the greater good and for the survival of the tribe. In some regions, such as West Africa, funerals can last up to an entire week. In China, if the deceased is older, in their 80s or 90s, the funeral becomes a celebration of sorts, and people are permitted to wear white and red rather than black. Each culture has a different way of letting go or of finding meaning in death. But at the present time in America, we struggle with this. Our small and fast dissolving family structure does not help – nor does a health care system which places emphasis on expensive, intensive, end-of-life care. Nor do overly optimistic physicians who cannot be frank with their patients about prognosis. But none of these isolated people or situations are to blame – the problem more complex than that, and it is not easily solvable.

The first point, which Gawande does not address in his article, is that age makes a difference. The elderly should think about their wishes for end-of-life care, and they should make these wishes known to their physicians and their families. They tend to have a much more difficult time surviving acute illnesses – myocardial infarction, pneumonia, even a urinary tract infection. And they should not spend endless days in the intensive care unit towards the end. For the most part, families have an easier time letting these people go. They want for them a peaceful death, without invasive procedures or aggressive resuscitation. If we take the time to ask, we are often able to make these patients comfortable sooner rather than later, and thus avoid the endless ICU admissions for patients in their 80s and 90s to which Gawande refers. This is the easier decision.

Every time a patient enters the hospital where I work, we ask questions about “code status” – whether or not patients want to be intubated or resuscitated. Some people are taken off guard by this, but once I explain to them why we ask everyone this question – and why it is an important question to think about – they become appreciative. Many patients have not thought about this question before coming to the hospital. I remember admitting an elderly woman with metastatic lung cancer to the intensive care unit several months ago. She was intubated in the emergency room prematurely – and this time, we were able to remove the tube in a couple of days. I asked her and her family if her oncologist had discussed with her end-of-life issues, such as how she wanted to spend these coming months and if she wanted to be intubated again. She shook her head – no discussion had taken place. Her family members hastened to answer the second question, saying that yes, of course she would want the tube, if she needed it to help her breathe. But I explained to them that, although the tube was removed this time, it may not be removed so easily next time. I told them that the disease we were treating – end-stage non-small cell lung care – was not responding well to chemotherapy, and that intubation – although possibly providing a temporary fix – would not take care of the true culprit, which was her lung cancer. They still insisted that she would want the tube. She sat there in front of me, unable to speak (at that time, she was still intubated). I told the family that I respected their comments, but I also told them that it was important to include her in the decision – it was, after all, her life. They agreed with me. I handed her a piece of paper and a pencil, and, after answering all the questions she and her family had, I posed the question to her. “Mrs. R, ” I said, “now that we have discussed all the possibilities, I want to give you the chance to tell me and your family what your wishes are. It is very likely, even if we take the tube out now, that you will need it again in the future. There is no predicting when this will happen – it could occur today, or it could occur months from now. But there will come a time when you will need it again. Is this something that you would want done again, to prolong your life?” She looked around the room at her hopeful family, then she wrote down a sentence and looked straight at me as she passed me the paper, where four words were written in capital letters, “I don’t want it.” There was a quiet in the room, but her family no longer insisted or disagreed with her. In fact, over the course of the next few days, they became more at peace with her decision and seemed content that they now understood very clearly what she wanted.

The more difficult patients are the younger ones. They, their families, and even we as physicians want them to survive. This hope often blinds our objectivity and skews the picture. It makes it harder to let go. When these patients ask me if they are dying, I often think to myself, “I know you are young. But everybody is dying. In the end, the survival rate is 0. It is not a question of if, it is only a question of when. And, although some of us may need to think about these issues earlier than others, we should really all be thinking about them.” I have taken care of young mothers with metastatic cancer and liver disease, in the emergency room and the intensive care unit. These patients are difficult. I often find that I am sad to walk in to their rooms and that I become naïve and hopeful – no longer a physician but an optimist – in the presence of them and their families. It is a natural reaction. Nobody this young should die, right?

Wrong. Even if it is not just, death can come at an inopportune time – right after the birth of a child, just before someone’s 21st birthday. Whether we like it or not, whether we agree to it or not, it happens. This sounds harsh. But I strongly believe that we owe it to our patients to be honest – not to take all hope away, not to place a time limit on their lives (for who are we to know?), but to be frank with them about whether we really think we can cure their disease. Even diagnoses without the frightening word “cancer” at the end can kill people – we saw that this past fall with H1N1, when young people in their teens, 20s, and 30s died in intensive care units across the country from a devastating flu. And diseases such as COPD and CHF are also terminal illnesses – although they may persist for years, there is no cure. Some patients who take medications for these diseases fail even to mention them on their past medical history – they figure, since they are taking a medication for it, they must no longer have the illness. They could not be more wrong – and, although end-of-life issues are a complex problem involving society, culture, and family – I think that doctors have a responsibility to step up to the plate when it comes to these diagnoses and to be frank about them.

But honesty does not mean taking away all hope. There are two things that I focus on when I am caring for patients at the end of life.

(1) “Doing everything” is not necessarily a good thing. We often perceive it that way, because we can write down something we have accomplished. But with every intervention comes risk – even with simple procedures, like placing a chest tube in a patient who is dying of lung cancer, there is a risk of infection or bleeding that could potentially be fatal. All interventions are not good interventions, and many times the invasive procedures that we can offer in the ICU do more good than harm. This helps families to feel that not “doing everything” also means avoiding potential pitfalls for their family members. It does not mean giving up.

(2) Even aside from hospice and medical care, there are other things we can offer patients. I watched my grandmother spend her last days in her home, after having Reiki performed by a neighborhood friend. She was more at peace after a Reiki session than she had been after any of her hospital visits. Other alternative therapies can be used as well – everything from acupuncture to meditation to yoga. These therapies will likely offer just as much evidence-based benefit as medical therapies for end-stage cancer (essentially none), but they will also make patients feel better, more relaxed. They will allow patients to enjoy their last days. Certain case-based studies indicate that they may prolong life, even if only for a short time.

Quality at the end of life is just as important as quality at the beginning of life. Dying a death under white lights in an ICU, on a ventilator, with lines comes out of every orifice of the body, is not a quality death. We should be proactive about letting our ICU patients know that it does not need to be this way - they can spend their last moments at home, with loved ones, with music playing, and with the goals of their care aimed towards comfort rather than cure, towards peace rather than chaos, towards calming rather than painful treatments.

If we extend our perspective beyond the health care system and the intensive care unit, and if we look even further into historical and cultural differences in end-of-life issues, we will become more enlightened about what a meaningful death really is. In the end, it is a private decision. But, as physicians, we can help our patients come to this decision by gently urging them to think about their wishes and by being open and comfortable in our discussions with patients about end-of-life issues – this will help both them and their families become more comfortable with it as well.

Even if a patient is dying, we still need to be good physicians. And, at this stage, the nature of our job changes but the tactics remain the same – we should present our patients with all the options, answer all of their questions, and encourage them to decide for themselves how they would like to live and how they would like to die. We should listen to them, we should care for them, we should not abandon them at this stage, and our path to good medical care should not be thwarted by their or our own hope – as a physician once told me, plan for the worst, hope for the best. That is the most we can do.

Anatomy Lab

Anatomy class at San Diego Naval Hospital, 1940

After reflecting on anatomy lab in the last post, an article in The Wall Street Journal piqued my interest today, At One Med School, Volunteers Lend a Hand With Anatomy Lab Prep. I recently revisited the anatomy lab as resident in order to practice clinical procedures.

The history behind anatomy lab is quite fascinating. During the late 1700s and 1800s in America, as medical schools expanded across the country, the demand for cadavers for medical student education increased dramatically. Interestingly, many medical schools were built close to a graveyard so that bodies could be transported quickly from the uprooted grave to the anatomy lab.

Body snatchers, also known as “resurrectionists,” stole corpses from graveyards for medical education. An article by Kenneth Dillinger, The Very Lucrative Business of Body Snatching, explains how resurrectionists made a business of providing bodies to medical schools. Because refrigeration had not yet been developed, it was important that the cadavers were “fresh.”

In the Scottish city of Edinburgh, William Burke and William Hare decided to take grave robbing one step further: they began murdering people to sell them to anatomists. This method, which became known as “burking,”  spread to America. Dr. Henry Howard Holmes, an American resurrectionist, is known for murdering several people. Some students paid tuition in corpses. Anatomy professors themselves participated in grave robbing. The poor, of course, were the most vulnerable because they could not afford coffins to keep the body snatchers out.

In an attempt to discourage “burking” and other acts of grave robbing, laws passed in the 1830s allowed physicians to dissect unclaimed bodies. By the 20th century, body snatching had essentially disappeared. Interestingly, in 1945, an article in Time discusses the Cadaver Crisis. As a result of death at war, there was a national shortage of cadavers. Medical schools relied on unclaimed bodies for their supply, and there was a growing concern that in the coming years there would no longer be enough cadavers to supply anatomy labs.

Anatomy lab is still a rite of passage in medical school. A question up for debate is whether or not medical students need anatomy lab to learn anatomy. With three-dimensional computer programs and SimMan (bodies which are becoming increasingly advanced in their simulation capabilities), it is possible to learn much of human anatomy through technology. Do we really need to dissect bodies anymore?

One of the disadvantages of anatomy lab is that is it not realistic. The vital organs, once embalmed, pale in comparison to the live organs which we view in the operating room. Sometimes they are not even recognizable. One of the important parts of anatomy education is understanding the spatial relationships between different organs, vessels, and landmarks – but these can be visualized in other ways.

A more limited anatomy experience, supplemented by new technology, might strike a good compromise. Many of the things we learn as first or second year students in anatomy lab are revisited in a much more meaningful way during our clinical experiences. In retrospect, anatomy lab makes much more sense to me – after years of practicing medicine on living, breathing patients, I better understand the human cadaver. I can distinguish what on the cadaver is useful or irrelevant. I understand the difference between the organs of the living and the deceased. As a medical student, I knew none of this.

Tactile learners will argue that anatomy lab is an essential part of medical school – some of them remember their anatomy vividly from their extensive time spent dissecting. Others had a difficult time with the dissection process and swear never to return to anatomy lab again. I fall somewhere in between.

The more important aspects of anatomy lab, which are often overlooked, are the emotional and psychologic effects  of dissecting another human being. Wonder, terror, guilt, and privilege – all of these emotions coursed through me on a daily basis. I used to sprint to the top of a hill after each lab session in order to release these emotions and feel alive – feel human – again.

One of my laboratory partners routinely logged on to a nearby computer to bring up pictures of young kittens as we dissected. We would all look at them and feel better, momentarily. Then, realizing the juxtaposition of the kittens and daunting tasks which lay in front of us for the day, we would start laughing, then grow quiet. This is what I remember most from anatomy lab: the uncomfortable laughter followed by sudden, awkward silences.

The purpose of medicine is to heal, to suture back together, to reduce dislocated hips, to reset bones – and here we were doing the exact opposite. Here we were, destroying before we had ever healed. Stuck in reverse. It was such a bizarre place to be. I felt that joining my colleagues in medical school was like stepping on a train with an unknown destination. But to arrive at our very first stop, anatomy lab, the wheels were rolling back. Where were we going after all?

If the purpose of the anatomy experience is to create distance between ourselves and the patients we treat, mission accomplished. (But should that really be our goal?) I haven’t  looked at people passing by on the street the same way since my intimate experience with dissection. That said, I often push it to the back of my mind, and eventually it slips away into my memories, only to be recalled on command. But, if I let myself think for more than a split second, vivid memories of the lab flash in my mind – memories which can only be understood by someone who has gone through the entire process, the entire journey, themselves.

In the end, I am ambiguous. Maybe in years to come I will formulate a stronger opinion about what anatomy meant to be. But now, over five years later, I am still left with a vague sense of discomfort and a curious sense of wonder. Although I wanted to live up to our donor’s expectations of what she would be offering us, I am still not certain that I achieved my goal.

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