Cardiology fellows strut in coffee stained lab coats and 2 day old scrubs.  Too tired to make eye contact with the intern who is gathering his notes to place in the chart.  Which is given to the private attending, who writes with a bemused expression as a nurse chides him about “the good old days” when he was given orders.

The day is filled with phone calls, orders, a rare procedure.  Patients are reassessed and reassured.  Families vent.  The night is long and patients are seen, examined, orders placed.  An alarm breaks the through the gentle din and this time it is real; as the nurses move the “code” cart silently outside the room…  “No atropine!  He has a transplanted heart!” and apply pacemaker leads to his chest faster than I can realize that he was in a dangerous rhythm with a very slow heart rate.  I nod my assent and follow their lead.  They were right.  And once again, I am humbled.

She was anxious…could she have something to help her sleep? I walk into the room where she is seated cross-legged on her bed, holding court with her parents who nod and smile their understanding. I have walked into a conversation, suspended in midair, paused to allow my intervention. She smiles, “I just feel…anxious?” Her inflection rises and becomes a nervous giggle, which punctuates many of her sentences. It is charming, her face is dimpled in a smile. She doesn’t know why – she isn’t short of breath – no palpitations…just anxious. Her parents don’t seem to comprehend my questions and smile at me, expectantly. No questions, only calm belief in my competence. In her blue head scarf, she looks like the girl with a pearl earring and she tells me she has had IV Benadryl in the past…can she have that? sheepish giggle. I return to general medicine service for a split second and negotiate IV Benadryl. Her eyes are warm and russet, glistening with fever or the remnant of tears. And in this moment I would give her anything she desired. I listen to her heart, lungs, abdomen…all normal. Only her head scarf and dark circled eyes belie her cancer. I linger, as the conversation remains suspended and am reassured of her anxiety.

That is my only memory of her. The rest is in laboratory data, radiologic images, pathology reports. She is transferred to the intensive care unit the following day, septicemia overwhelms her. Stripped of her immune system from cancer and chemotherapy, she has no defense other than our antibiotics. Am I really sick? She asks her intern, that same question punctuated by a giggle, as she is wheeled from our ward to intensive care.

Had she known that night? That her cancer had returned with vengeance, found in sheets of cells on biopsy and resistant to chemotherapy.

***

The death of an innocent is always more difficult to bear. We share sad smiles, concerned brows, soothe ourselves with, “there was nothing more to offer…”, review the bone marrow slides again to imprint the malignancy in our minds and reaffirm that we were impotent in the face of disease. We rationalize our grief and turn to the days work to expunge the remaining cancer in the ward. With the hope of a future with no more sacrificial lambs.

But,

She persists. She haunts our ward and I see her in the dimpled smile of a nurse’s aide, the Guatemalan name of a patient, the delighted laughter of a child. I know that she is just under the surface of our thoughts and she returns unexpectedly. The secretary stops stapling to look up at her former nurse, “It was such a shame…” They nod. Her intern is pensive, and conspiratorially whispers, “I’m checked out…I’m so tired of this.” The attending sighs more often, and laughs even less.

The next night, I dream – and just before I fall asleep I have a vision of our morning rounds. We are seated at the long table, and our attending says, “Let’s begin this morning with a moment of silence. In remembrance of the life we have lost.” I furtively glance up at my attending, his eyes are rimmed with red, his jaw set firm. I watch my resident close his eyes in prayer, her intern inhale deeply, the pharmacist rearrange his features in concern. We are one, in silent space before the motion of the day.

She calmly smiles, and walks away.

So heartbreakingly young. She was anxious…could she have something to help her sleep? I walk into the room where she is seated cross-legged on her bed, holding court with her parents who nod and smile their understanding. I have walked into a conversation, suspended in midair, paused to allow my intervention. She smiles, “I just feel…anxious?” Her inflection rises and becomes a nervous giggle, which punctuates many of her sentences. It is charming, her face is dimpled in a smile. She doesn’t know why – she isn’t short of breath – no palpitations…just anxious. Her parents don’t seem to comprehend my questions and smile at me, expectantly. No questions, just the calm expectation of my competence. In her head scarf, she looks like the girl with the pearl earring and she tells me she has had IV Benadryl in the past…can she have that? sheepish giggle. I return to my general medicine service for a split second and negotiate IV Benadryl, hypothetically habit forming but am returned to oncology, and that would be a luxury. I listen to her heart, lungs, abdomen…all normal. Only her head scarf and dark circled eyes belie her cancer . I linger, as the conversation remains suspended and am reassured of her anxiety.

That is my only memory of her. The rest is in lab data, CT reports. She is transferred to the ICU the following day, septicemia overwhelms her. Stripped of her immune system from cancer and chemotherapy, she has no defense other than our antibiotics. Am I really sick? She asks M, that same question punctuated by a giggle, eyes widened as she is wheeled toward the ICU.

What had she known that night? That her cancer had returned with vengeance, found in sheets of cells on biopsy and resistant to chemotherapy? That this was one of her last nights? What would she have done if she had known?

The death of an innocent is always more difficult to bear. We share sad smiles, concerned brows, soothe ourselves with, “there was nothing more to offer…”, review the bone marrow slides again to imprint the malignancy in our minds and reaffirm that we were impotent in the face of disease. We rationalize our grief and turn to the days work to expunge the remaining cancer in the ward. With the hope of a future with no more sacrificial lambs.

What if we began the next day’s work with, “a moment of silence, to remember her life…” ?

My first bout with Killer Fatigue was in November, after my vacation home to the midwest. I began work on the General medicine service, the ward service that cared for the underserved: the homeless, drug addicted, immigrant masses of my fair city. In theory this is noble — and I filled many a personal statement/essay question with my desire to serve the underserved, I sought residency programs with diverse patient populations neglected or marginalized by our healthcare system, caring for the indigent resonated with the very core of my physician being. I’d read the canon: short stories by William Carlos Williams, Chekhov, “Mountains Beyond Mountains”, was inspired by the works of Albert Schweitzer, Paul Brandt, was moved by the sensitivity of Abraham Verghese.

And this sustained me through one week of the rotation.

My reading, preparation hadn’t prepared me for the reality of my patients. They didn’t see me as their white-coated healer — no I was a symbol of an impersonal and fragmented healthcare system, subject to distrust, sometimes wary approval. I was a pathway to narcotics or benzodiazepines. A means to an end.  And the front line to myriad complaints about our system of care — most of which were beyond my control.  Can only empathize so much before frustration builds and fatigue seeps in…

“I’ve been so anxious…I’ve been through so much…” “Doctor, you’ve got to give her something — I think that she takes 3 Xanax a day at home…she might go into withdrawal!”

Vital Signs: HR – 110, RR – 22, Oxygen saturation on room air at 3p.m. 96%; at 7p.m. 92%; at 9p.m. 88% and 2 L oxygen through nasal cannula applied to oxygen saturation of 93%.

“Why is she hypoxemic? I’m not treating her respiratory distress with ativan!” I don’t mean to sound harsh, but I do. It is 2a.m. and I’m the lone intern on the oncology ward with 21 patients and 21 different cancers and comorbidities. The nurse huffs a bit and hovers…”She could seize!” Indignantly charting…

Shuffle through papers with high-lighted and check-boxed notations myriad hieroglyphic patented “Doctor” handwriting scrawls the keys to unlocking all manner of cross-cover mysteries. Given a 2.5 cm space to summarize our patient, we are forced to give the most pertinent details when transferring care — of course we can’t fit everything in that space. And I come to 345-B. “CTCL rx with radiotherapy. Diarrhea x 2days. Stable and going home tomorrow. Couldn’t find a ride.”

Sigh.

Find the chart. Briefest skim of info — and A/P reads “DVT, on lovenox therapy”. Interesting.

so Oncology at night, with its wraith-like creatures that roam the halls, desperate for sleep, peace, tomorrow, water, a better prognosis. I didn’t realize how their images would haunt me as I try to sleep post-call. How my elbows…from this angle reminded me of Mr P’s vertebrae…how that beveled needle slipped past the many layers of fascia, then entered the subdural space. How happy I was to see clear fluid drip on the cloth below. Then the kiss of Narcan used to awaken our patient from his 4bpm slumber after. His blood teeming with HIV.

“How do you feel?”

“Just terrible“

She labors to breathe and tells me she’s anxious, not short of breath. bilateral wheezes. her skin is reddened, scaled, and flaking off her body as she frantically scratches…”I scratch a lot when I’m anxious!” her eyes tiny beads in her edematous, reddened face…I stand in the changing light bathed by the TV…. i tell her i’m worried about her breathing…i want to give her a breathing treatment. she sighs her displeasure…

…and I leave to pronounce Mr. H…who relinquished his life at 2:26a.m. His wife, who has always known what to do — looks lost for a moment, “What do we do now?”. We’ll take care of the body — you contact the rest of the family — you don’t need to do anything . Her eye wells in tears — her face is not used to crying — “thank you all”. I don’t have the beautiful, meaningful words that I’d like to say…to bring about a moment, something profound that would help heal her heart…help her grieve. I reach over to touch her hand and she grasps mine for a moment…and I nod and say, “i’m sorry for your loss”

CTCL lady’s nurse asks “where is her ativan?” as I return to the floor. “what is her oxygen saturation?” “It’s 95% on 2L now after the nebulizer” I sigh…and consult my resident. Her need for oxygen is concerning, especially with the history of DVT. The clot in her leg may have traveled to her lungs, creating a mismatch in ventilation and perfusion — simply: no blood flow to part of her lung = oxygen rich air unable to enter the blood and so the body’s blood contains less oxygen overall to properly function. She already being treated with lovenox, though, which is the treatment for pulmonary embolus as long as her blood pressure remains stable.

Write an order for a small dose of ativan and return to her room, she is angry, interrupting to scratch her skin furiously. “I’m so anxious…I can’t believe I’m here again…you don’t know what I’ve been through!” i explain why i didn’t order ativan promptly, she continues to tell me, disjointed, but “i’ve been sick for 10 years…they all thought that I was just anxious. i kept scratching. scratching and went to several doctors who told me the same thing. it’s nothing…and then i remarked to a co-worker, ‘i’ll bet its cancer’…and they biopsied a spot on my belly and it was. i’ve had so many chemo and radiation therapies. they irradiated my entire body and i was so sick. one day i was eating a hamburger and felt something so strange…i looked down at the burger and all of the teeth in my lower jaw fell out into the meat. they never told me this would happen. and another doctor told me that they usually pull out all teeth before radiation therapy like the therapy i had.”

riveted, revolted, i can’t move as she continues…”i was so angry with you…why couldn’t you give me just a little ativan?” she tells me a bit more of her story…then scratching less, she stops and looks tired for a bit, “thank you for coming…i’m sorry for wanting to punch you…” i hold my hands up, together, bracing “you can give it a shot…go ahead!” she smiles and instead grabs my hand, “thank you for coming in and talking to me”

I leave the room.

And the nurse walks in with ativan.

Nephrologists are reverentially referred to as “The Smart Doctors” by internists and surgeons alike. Well-versed in the complex physiology of the kidney, they are also expert at managing electrolyte, acid-base, and fluid disturbances in the wards. They know eponymic equations by heart and can “fix” kidney failure with dialysis or CVVH.

Enjoyed this rotation, there was nice overlap with critical care — my first patient was transferred to the MICU. I missed the intensity and quick decision making found in critical care. I was a “white cloud” for the service and we had few consults. My first patient died in the MICU (metastatic GI cancer newly diagnosed…) and my second patient had a fascinoma and metastatic ovarian CA. The zebra was: xanthogranulomatous pyelonephritis. Sweet lady — didn’t trust doctors and hadn’t seen one for 7 years. She was one of two female patients who presented the same day with kidney failure partially due to obstruction. I told my attending that I suspected they both had cancer. He told me I was cynical — it was only the 4th month of my intern year. Unfortunately, I was right.

I received some encouragement and nice feedback from my attending, who was primarily a basic science researcher. I felt comfortable asking questions, learned to think more critically about the literature, and was reminded of the importance of skepticism in medicine.

I’ve had very sick patients thus far, and have had many experience with dying patients. I don’t know if I remember these patients more because of my interest in EOL care or if I really have had sicker patients. As I begin another rotation with very sick cancer patients, I’m struck with how many very ill, and dying patients the average intern faces with little preparation re: emotional repercussions, family discussions, etc from medical school or even residency training programs.

Dr. S provides a wonderful model of how to hold family discussions, but my MICU experience differed far from the average intern even in this program. We have many wonderful didactics but few prepare us for effective family conferences, the reality of our patients prognoses, the possibility of burnout…

For thou art with me.

Completed my intern month in the ICU. These words have new meaning for me.

Bearing witness to the pain of death.  Sometimes it is the only thing we can offer to our patients, our families.  It’s a bit like staring at the sun, though.

Trying not to go blind.

First time I’d seen a smile from my patient in a while. He was excited because his girlfriend of 10 years was visiting that day. Was already awake when I walked in at 6:30, asking for a new razor, cleaning up and preparing for her arrival. The team stood outside his room during rounds, while Billie’s melancholy voice sang “god bless the child”…

I’d asked the oncology fellow if they could discuss prognosis and code status with him. The plan was to do so at 1p.m. on Friday, when his girlfriend would be present.

1:15p.m. (late) I walked into his room and saw his sister. No girlfriend. And no oncologists.

So I sat and talked with them. It felt like the right thing to do. It was my first time breaking bad news. I know that the oncologists had spoken with Mr. C the previous day re: his cancer and that they had stopped chemotherapy. And I thought I’d prepare them for the oncologists return later that day. I didn’t ask them to make any decisions today — just that there were things to think about for the future. And I told them that he would most likely die from his cancer, though we didn’t know when.

It was difficult…and sad. I was angry that his girlfriend didn’t show… I then paged the oncologist, telling them that Mr. C and his sister were waiting to speak with them. The fellow told me that they were very busy, but that they would stop by later when they could… And I was then angry with the oncologists.

Thankfully, my attending found me in the charting room shortly after the conversation. She was sympathetic — and found the oncologist — who was then ready to begin the family meeting. We returned to Mr. C’s room and found his girlfriend present — along with his sister and a friend. Oncology then held the definitive discussion — and answered a lot of questions from the patient and his family. I was present through it all.

What struck me most, was the audible gasp through the room when the oncologist said the word “hospice”.

It is a shame that palliative care is tied into the Medicare hospice benefit, which dictates that a patient must have a prognosis of 6 months or less. We cannot prognosticate accurately…and people are left with a sense that their doctor is “sentencing” them to death… Most hospices do not allow for “curative” treatments such as radiation therapy or chemotherapy for hospice patients, even though the treatments are not curative — they may only shrink the tumor so that symptoms are more bearable or the risk of a catastrophic hemorrhage is decreased. So patients are left with the choice of continuing therapy and not having their symptoms managed ideally, without the social, spiritual, emotional, caregiver support that hospice can provide. Hospice “bridge” programs are beginning in some institutions, but are generally a rarity.

In an ideal world, palliative care and the resources of hospice could be instituted for anyone with a chronic, terminal illness who needs better symptom management…regardless of the estimated length of time until death…because we are so bad at determining this. Much of the focus of hospice in america is on “the good death”. In an ideal america, palliative care would focus on LIVING WELL and without unbearable symptoms until death. …Cecily Saunders (who started the hospice movement) said, “You matter because you are you. You matter to the last moment of your life and we will do all we can not only to help you die peacefully but to live until you die….”

Conversations about hospice in the U.S. have the subtext of “no hope…6 months or less…” It is not surprising that most people aren’t enrolled into hospice until 72 hours before their death.

I am saddened by Mr. C’s cancer. I feel a connection with him through our mutual love of music…and he has a quiet sweetness and dry sense of humor… I like my patient. It makes his dying difficult for me, but it also adds emotional resonance and motivation for my interest in palliative care and the vague desires I have to help change palliative care in our country.

Mr. C has been my patient from day one of this rotation. I inherited him. He was recovering from chemotherapy for nasopharyngeal carcinoma (large tumor in his R maxillary sinus/nasopharynx),3 weeks prior had coded during portacath placement, was intubated and spent a week in the MICU, given a trach and PEG tube there, then transferred to the SDU (step down unit) where I picked up where the other intern had left off.

A quiet man. Never complained when I’d brightly walk in each morning to spend 2-3 minutes to find out about his night/if he had any new symptoms/quickly examine him. Most of the time I didn’t wake him up. He’d simply watch me and give a half smile or nod.

Some patients demand your attention — and it is easy to respond to this. Whether it is through their plummeting blood pressure or hematocrit or through their incessant demands for pain medication or discharge or better food. Complaints are registered. In an effort to help the person…or to stop their unpleasantness…they are moved toward the top of the task list

And then there is Mr. C.

Transferred to the wasteland of the floor (where each nurse has 7 patients — each demanding time and attention…) and it is easy to miss subtle cues…signs of need. And I, with 7 patients, miss subtle cues…

As he did not respond to his chemotherapy, his pain increased, and he developed infections due to his low white count…

I readily responded to his fever, neutropenia, purulent discharge, but I missed that his sister visited only once in the two weeks I’ve cared for him. That his girlfriend visited once to get her rent check. An afternoon with my medical student trying to obtain blood cultures and I learned that he hosted a morning jazz show on college radio station for 32 years. That he loves Billie Holliday. That in his hospital room, he listens to the music in his head.

Today, he does not respond to antibiotics. He has no one to make decisions for him if he gets really sick. He is febrile, his white count so high that the lab was required to call his nurse. And I cannot contact his sister, who gave me her number that I shredded…sure that it would be in his chart(she said she had given it…). He does not have his sister’s number. His girlfriend is visiting on Friday.

Daily, I’ve seen his tumor grow. He now has R eye proptosis…his R face is paralyzed…and the pain is increasing yet.

***

I’m on a Pulmonary consult elective, so I feel as if I’m still a 4th year medical student most of the time. Not a bother — I’m getting used to the system and am learning the layout of the hospital.

In the anxiety of being a new intern, and trying to be efficient, smart, and focused on Pulmonology, today I learned how quickly I can forget the core values that drew me into medicine.

My patient was a middle-aged homeless man who was admitted a week earlier from the ED with hypoglycemia — his blood sugar was 31. He admitted to having lost 100 lbs. in 2 years…and described a year-long history of night sweats (”they might be panic attacks”), loss of appetite, dry cough, some shortness of breath. He had non-active Hep C, a 30 plus pack-year smoking history, and a hx of polysubstance abuse now on a methadone maintenance program. He underwent an extensive work-up for his hypoglycemia and constitutional symptoms: endocrine consultation, rheumatological panel, cancer markers, CT scans, MRI…all negative. We were consulted for the only positive CT finding: bilateral hilar lymphadenopathy.

I went to see this consultation with the desire to impress my attending and fellow. Bilateral hilar lymphadenopathy — a hallmark of sarcoidosis. …with his constitutional symptoms he may have an undetected lymphoma… With my intern zeal and attention to detail, I would be the first to discover the key to unlock my patient’s diagnosis! I spoke with the patient, confirming what I had read in his history. He was very soft spoken, with a sad inflection to his words…and readily answered my questions and let me examine him. He had a malar rash, clubbing of the fingernails…his findings lept at me like bullet points — the lungs — distant breath sounds — nicotine-stained fingers — the hallmarks of a chronic smoker.

Swiftly wrote my note…printed out articles on sarcoidosis and non-hodgkin’s lymphoma..determined to have formulated an assessment and plan by the time I met with the attending and fellow for rounds.

The attending listened to my history, exam findings, the results of the myriad tests, with a bemused smile. He then asked me, “Bellatrix, Does he look like he has lost 100 lbs in 2 years?”. I stopped…he did not look cachectic, the sickly wasting that occurs in cancer or AIDs or equivalent Badness…”Well…he looks thin…”. “Is he a straight shooter?” “He’s homeless…and has been a polysubstance abuser…”

“Is it possible that he’s been hungry?”

…

On review of the chest CT with our expert radiologist, she determined that the nodes were small enough to be reactive — not cancer. The attending sat with the patient and talked with him about his symptoms — and what had been going on in his life. He has no family — his parents died — no children — no lover. He’s worked construction up until 2 years ago, when he developed severe back and neck pain. …he then lived on unemployment…until it ran out…his savings…until they ran out…and then welfare. …he moved into the homeless shelter 2 months ago.

So…he’s alone. And hungry.

We could only advise smoking cessation…and primary care follow up for probable COPD. He probably has PTSD…and though we can’t fix his broken life, an antidepressant could help him. My medical school…my LIFE to this point…taught me the importance of treating the whole patient. Humbling in that it was so easy to forget!