The End of an Era

This marked the last day of my time in the coronary care unit. I leave with mixed feelings – mainly pure exhaustion and relief. At the end of a month in an intensive care unit, my emotional and physical strength are completely drained. I spend 28 days pouring every ounce of energy into these patients, their care – and suddenly, after what seems like an endless string of sleepless days and nights which blend together, the month is finished. I leave behind patients who will linger in my thoughts for some time.

Today my sentiments correlate well with a photograph I took on a foggy day along Pebble Beach Drive of the Lone Cypress. Solitude and a tinge of sadness, not for my departure but for my patients. It is nice to be in a quiet place after nights of beeping monitors, ear-piercing phone rings, and intrusive pager melodies. It is a relief to be removed from those circular intensive care units, with glass doors lining the circumference – all too stark a window into every breath, into every moment of my patients’ lives. Sometimes I feel as though I am in the center of a spinning merry-go-round, walking, running in one direction and then another. But the spinning sensation is all from my movement. The patients are still.

And this merry-go-round with its glass circumference is a precipice – surrounding us are the sheer cliffs which separate life from death and which plunge into the ocean’s depths. We build this structure, a well-functioning machine with its rhythm and noises, powered by our own incessant movement. But the structure is more fragile than it seems – the glass ready to shatter and the moving parts on the brink of halting. Even in the best intensive care units in the United States of America, we are not invincible.

R. Fitch made the first newspaper reference to the Monterey Cypress on January 19, 1889. “Rounding a short curve on the beach, we approach Cypress Point, the boldest headland on the peninsula of Monterey. Down almost to the water grows the cypress, and on the extreme point a solitary tree has sunk its roots in the crevices of the wave-washed rock, and defies the battle of the elements that rage about it during the storms of winter.”

The lone cypress tree, springing from rock, has withstood the test of time – it has withstood the barrage of the elements for over 200 years, including wind gusts up to sixty or seventy miles per hour. It has survived. But the tree has roots which date back even further. In Greek mythology, the cypress tree was named for Cyparissus, a youth from the island of Cea, son of Telephus who was loved by Apollo. He mistakenly killed his favorite stag. Overcome with grief, he metamorphosed into a cypress. As a result, the Cupressus sempervirens, or cypress tree, is the principal cemetery tree both in the Western and Muslim worlds. Below is an excerpt from Metamorphoses.

Ovid, Metamorphoses 10. 106 ff (trans. Melville) (Roman epic C1st B.C. to C1st A.D.) :

“In all the throng the cone-shaped cypress stood; a tree now, it was changed from a dear youth loved by the god who strings the lyre and bow [i.e. Apollon]. For there was at one time, a mighty stag held sacred by those nymphs who haunt the fields Carthaean [i.e. on the island of Keos]. His great antlers spread so wide, they gave an ample shade to his own head. Those antlers shone with gold: from his smooth throat a necklace, studded with a wealth of gems, hung down to his strong shoulders–beautiful. A silver boss, fastened with little thongs, played on his forehead, worn there from his birth; and pendants from both ears, of gleaming pearls, adorned his hollow temples. Free of fear, and now no longer shy, frequenting homes of men he knew, he offered his soft neck even to strangers for their petting hands. But more than by all others, he was loved by you, O Cyparissus, fairest youth of all the lads of Cea. It was you who led the pet stag to fresh pasturage, and to the waters of the clearest spring. Sometimes you wove bright garlands for his horns, and sometimes, like a horseman on his back, now here now there, you guided his soft mouth with purple reins.

It was upon a summer day, at high noon when the [summertime constellation] Crab, of spreading claws, loving the sea-shore, almost burnt beneath the sun’s hot burning rays; and the pet stag was then reclining on the grassy earth and, wearied of all action, found relief under the cool shade of the forest trees; that as he lay there Cyparissus pierced him with a javelin: and although it was quite accidental, when the shocked youth saw his loved stag dying from the cruel wound he could not bear it, and resolved on death. What did not Phoebus say to comfort him? He cautioned him to hold his grief in check, consistent with the cause. But still the lad lamented, and with groans implored the Gods that he might mourn forever. His life force exhausted by long weeping, now his limbs began to take a green tint, and his hair, which overhung his snow-white brow, turned up into a bristling crest; and he became a stiff tree with a slender top and pointed up to the starry heavens. And the God, groaning with sorrow, said; `You shall be mourned sincerely by me, surely as you mourn for others, and forever you shall stand in grief, where others grieve.”

And so the lone cypress withstands the elements for centuries. It survives. It prevails. But the tree itself is a symbol of death and mourning, associated with the story of a young boy overwhelmed by grief and loss. Fragility lies beneath its outward resilience. The line between life and death is finer than we imagine.

Friday the 13th

Mens agitat molem.
Mind moves matter.
Virgil, Aeneid, 19 BCE

A full moon, captured in 2005 by a crew member of the International Space Station, appears to be rolling along atop Earth's deep-blue stratosphere.

Atul Gawande wrote an article for Slate back in 1998, E.R. and the Triple Hex, about whether more accidents happen when a full moon and a lunar eclipse collide with Friday the 13th. Although there is no hard and fast evidence that Friday the 13th, the lunar eclipse, or a full moon is associated with increased hospital admissions or illness severity, there is still room enough for us to entertain that possibility. The one piece of evidence that the moon may have an effect on us is that for women, menstruation typically occurs on the 28-day lunar cycle. This month’s full moon – August 24 – safely surpassed the 13th, but the hospital was chaotic through the late hours of the night nonetheless – and I daresay the chaos subsided as daylight broke on the morning of the 14th. The diagnoses from yesterday’s admissions to the intensive care unit – peripartum cardiomyopathy, persistent hypotension after carotid stenting, myocardial infarction with minimally improved cardiac function after balloon angioplasty and stenting, acute renal failure requiring hemodialysis after cardiac catheterization – were striking in their unusual nature and their degree of severity. The emergency department was filled beyond the point of overflow – the census of critically ill patients downstairs was comparable to the holidays.

The degree of superstition in the hospital is quite remarkable, especially given the propensity of hospital staff – physicians, nurses, and PAs alike – to use logic and scientific evidence in their daily thought process. I have never uttered the words “quiet night” in the hospital without being told vehemently by someone in the near vicinity not to say such things out loud, for fear that it would “jinx” the night. For that reason, I am not as surprised as Gawande that researchers have tried to “prove” superstition exists with scientific data. As inquisitive, scientific people, we are looking for a concrete reason for our superstitions. We are looking to make our own anecdotal, intangible evidence both concrete and tangible. The easy explanation for superstition is that we are biased observers – on the night of a full moon or Friday the 13th, we look for – even expect – a high patient volume or increased severity of illness and attribute anything out of the ordinary to the date. We give people’s illnesses meaning within the context of time. In contrast, on other days we try not to think about it – we move through the day as usual and dismiss anything unusual to pure chance.

The concept of mind over matter does not only apply to Friday the 13th. Last night, a family gathered round the bedside of their father who suffered a stroke several weeks ago. Mr. K continues in a long, hard fight for recovery. His brain has undergone permanent damage from a stroke that has not completely resolved – a large clot still sits in one of his cranial arteries. He is lethargic and unresponsive at his worst, and he squeezes his hand in response to his family at best. He has not been able to speak or eat since the injury. He is now reaching the point where, from a medical perspective, we have done all we can to optimize his condition. As his family begins to take the next steps in his care and to answer the difficult questions of what quality of life might mean for him, they circle around the bed, sharing stories and memories through the years. In the room next door, a young woman who has just delivered a baby stays up all night with her husband – she has developed peripartum cardiomyopathy and is praying for her own recovery so that she can go home to care for her newborn. And in another room still, a middle-aged gentleman who suffered a massive heart attack fights for his life – with a balloon pump in his aorta to increase his cardiac output and with a breathing tube and ventilator machine to help treat his florid pulmonary edema, he will need to undergo much more than his initial cardiac stenting before he will be able to recover any meaningful, active life again.

Although quiet words about Friday the 13th circled among hospital staff last night, none of these patients or their families  mentioned it to me. Perhaps they were too distracted to notice. Or perhaps it didn’t matter.

The idea of mind over matter is an important one in the hospital – and although I am certain of this, I am equally certain that it is nearly impossible to prove. But patients’ and families’ mental state of health has a direct impact on their physical health, and even – I would venture to say – on their outcome. The mind plays a critical role in illness, far beyond what we can elucidate or fully understand as scientists. This is something that needs to be explored in greater depth, and as we gain a better understanding of it, we should integrate it into medical care. This is the “art” of medicine – and we should be embracing it, especially for patients whom we have little else to offer.

And so, on Friday the 13th, a plenitude of anecdotal and intangible evidence win out in the end, even in the hospital. I have learned from experience never to utter the words “quiet night” except in my mind. But if I think it to myself, maybe even then it is a silent jinx…

Dreaming On Call

I walk into the hospital today. It is just like any other day in the intensive care unit. Monitors beeping, nurses buzzing, patients and their families trying to make it through the day. I follow patients from the last year whom I have cared for on medical floors and intensive care units, for educational purposes and to see how well my care benefited them. But I always dread this investigation – many of them are sick, and as I scroll through their names I hold my breath and hope that they have made it through at least their most recent hospitalization. One name made my heart sink today – a young woman who spent over a month in the intensive care unit. She fought hard. A mother, a wife, a sister, a daughter. When I look at the cold medical term in capital letters beneath her name, expired, a sense of regret rushes over me. I want – instinctively, naïvely – to go back in time and be there at the moment that she declined, to change the past. Impossible, of course. But I wish for it nonetheless.

I stop scrolling as soon as I get to her – I can only take so many hits in a day, so I leave the follow-up on the rest of my patients for another day. I already know that her story will be on my mind during this long call night. When I doze into a shallow sleep, I begin to dream. I dream that  dozens of patients in the intensive care unit are stranded on a beach with flat wooden boards as back boards. The water is washing over them, the island is flooding. I am the only physician there. I am trying to save them all as the water level rapidly rises. But it is impossible. I cannot even carry the sickest ones. So I begin to do “reverse triage” – treating the less wounded before the more wounded, in an attempt to use the limited resources I have. This technique is often used when resources are completely overwhelmed, or in cold water drowning and lightning strikes.

I drag an eight-year-old Guatemalan girl who is shouting my name to safety. I search the crowd for more people. And that is when I see her, on a flat wooden board, with water washing over her face. Her hair is disheveled. Her face is turned away from me. The waves are coming. She is pale, barely breathing. I try to move her. She is unable to speak. The board is cumbersome, and the swells are getting larger. My heart races, and I keep trying. But she will not move. No matter what I do, I cannot bring her to safety. I look around for help, but there is nobody. She is dying in my arms as the waves rush in. I try to bring her to safety, but she will not budge. I panic. That is when I wake up, in a cold sweat.

In daylight, and in the face of death, I remain calm, completely composed. I complete my 30-hour call shift smoothly – they are so routine to me now that I barely notice how long I have been in the hospital or how little I have slept. But the dream stays with me – vividly. And in spite of my calm, in spite of all the growing I have done as a physician, I sometimes feel exactly as if I am still in this dream, trying to make possible the impossible, trying to save lives that – no matter how much I do – cannot, will not be saved.

Arctic Sun

Sometimes even medicine has rather poetic, heart-stopping concepts – Arctic Sun is one of them. Take a patient who has flatlined – died momentarily, if you will, with a motionless heart for up to 60

Gates of the Arctic National Park, Alaska, National Geographic

minutes – and freeze him down to a temperature of 93F (34C). Make him cold as death. It is closer to science fiction than it is to medicine – but it is fast becoming a procedure which we use for patients who have suffered a cardiac arrest. Overall, it seems to improve outcomes. The goal is to slow metabolism after a cardiac arrest in order to minimize damage to the brain and. heart.

Taking care of patients on “Arctic Sun” is difficult for physicians and families. It is a waiting game, at least in the beginning. There is very little we can do for the patient during this period except care for them as best we can and hope that they make it through. And then we watch – as they rewarm, information is slowly revealed to us about how effective the cooling process was.

The concept of cooling cardiac arrest patients emerged as early as 2006 in medical news, refer to articles such as Cooling Techniques Help Save Heart Attack Patients. Stories continue to emerge about survivors who have made it through Arctic Sun. Interestingly, cardiothoracic surgeons have been using the concept of cooling patients for repair of thoracic aortic aneurysms for several years – patients are cooled, then placed on a heart lung machine, and surgery is performed. The concept is now spreading to emergency departments and coronary care units across the country. Several articles published in 2009 Critical Care Medicine discuss some of the important aspects of “therapeutic temperature management,” as it is called.

It is a strange concept – to touch these patients at their coldest phase in the process is quite surprising. And to watch them go through the slow process of rewarming is equally strange – it is as if you are watching them come to life again. In any event, it provides us with still more evidence that we continue to push the boundaries of medicine – and of life and death – in this country. The name is fitting – these cooling gel pads can sometimes represent a sharp white ray of hope in an otherwise desolate land of poor outcomes.

On Becoming a Physician

It is hard to imagine that someone can emerge from intern year – 12 months of chaos, little sleep, and hours upon hours spent responding to pages and putting orders in a computer – and know something, anything, about medicine. I did not believe in this training system until now, after my first night as a supervising resident. The knowledge I have absorbed over the past year is finally flowing, smooth as water, and I continue to surprise myself.

I recently had to go back over the last year and place a final signature on all the documents I created  – in three months that I spent working in the medical and intensive care units, I wrote over 300 patient notes. Over the course of the last twelve months, I have seen thousands of patients walk through the doors of this hospital. I have diagnosed, cared for, saved, and lost lives – too many to count. I have watched a new mother hold her child for the first time. I have stood by families whose children are dying under my care. I have watched patients my own age struggle to survive. I have cared for friends of friends, people whom I knew long ago in a different context. I have watched the world through the eyes of this hospital – every heartbeat, every breath, every minute.

And this hospital, in a very strange way, has begun to feel like home. I have spent so many sleepless nights here. I have cried behind its closed doors. I have watched rain, snow, and sun through its windows. I have spent time in so many hidden corners of this building – and I would like to hope that, when I have completed my years here, I will have left a trail behind me of a small spirit, a small presence, for my patients.

As I retrace my paths in this place time and time again, I realize – only in retrospect – that, without my realizing it, my steps have become more certain. Somewhere along the way, I stopped being afraid of the hospital. And somewhere along the way, I stopped being afraid that I was not capable of becoming a physician.

Last night, as I watched my intern in his attempt to draw an arterial blood gas, I guided him only with my voice. “Increase your angle, move to the left, increase your angle more, withdraw slowly. Keep it still.” And I guided him with ease until he was right in the vessel – blood filled the syringe. Success. Not by chance. He looked up at me, surprised at his success, as if to say, “How did you…?”

But he will not know the answer to this question until much later. The answer lies in the hours upon hours that I have labored to place lines on sick patients. The answer lies in the countless nights I have spent at my patients’ bedside, knowing that the nurses and my patients are relying on me. The answer lies in the life of the intern – giving up everything to prove to everyone else – and to yourself – that you are a doctor.

When no one in the intensive care unit can get an IV line on a patient, I use the ultrasound to find a vein and place one. When anxious nurses and interns struggle as a patient codes, I am the one who establishes calm. When a patient is sick, I am the first to come to the bedside – no longer as a haggard intern, but as a doctor who wants to make my patient better.

This did not come easy. And it did not come without a price. But, having come out on the other side, it makes me realize that there is some good we can do in medicine, in spite of all its flaws. There is something special that we can offer if we act as compassionate physicians. And the reward – gratitude from patients and their families – is humbling. It restores some of my faith in humanity – that we can all appreciate one another, work together to care for one another, and help to make the rough spots in life a little less lonely, a little more bearable.

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