These Healing Hands

It's a reality in medicine that sometimes your patients die, and patients generally do not take exception to this fact if they happen to be cared for by a medical student. Some deaths can be more difficult than others as a student, depending on how well you got to know the patient beforehand or the circumstances of their death. Throughout my third year of medical school, I had several patients who I was caring for pass away while I was on service. Generally, these deaths were of one of two varieties:
(1) A healthy individual crashes and burns, a code is called, and we try our damndest for hours to fight the inevitable tide of death. Eventually the code is called, the team collapses in exhaustion, but there is a certain amount of solace to be taken in knowing that we tried everything.

(2) An individual with end stage x disease, who has been playing ding-dong-ditch at Death's front door for far to long, finally catches Death as he/she is walking by the front door in a bath robe and passes quietly in the night. News of these deaths comes during the AM handoffs and is generally met with a general sense of "Damn." but part of your psyche had already begun stacking the sandbags, knowing full well that your dying patient was, well, dying.

I had another, unique experience with death while on my neurology rotation. We had been consulted on an elderly woman admitted with altered mental status, in the classic CYA consult "rule/out stroke" that elderly patients with AMS tend to collect as they pass through the ED. I originally went to examine her with my attending in the AM, to find a frail looking woman, eyes open staring directly at the ceiling, unresponsive to anything in the room around her. She was altered (frankly, encephalopathic), but we did a full exam anyways and determined that she most likely did not have a stroke. Her breathing was shallow, raspy, and moist, a death gurgle of sorts as she was having difficulty handling her secretions. Labs would show a CO2 of >150... the likely culprit of her current stuporous state.

We weighed in our opinion and were off to clinic for the day. When the late afternoon rolled around, I decided to check back up on her, anticipating that after the requisite therapy for her COPD exacerbation, she would be doing much better. Luckily, I decided to glance at the chart before entering the room, and found a note from the medicine team "Discussed situation and prognosis with family. Family wishes DNR/DNI, palliative care consult."

I enter to find her much as she was that morning. Eyes open, staring blankly at the ceiling, still unresponsive. The late afternoon tends to be quiet in this wing of the hospital, and it was just her and I and the setting sun through the hospital window. Her raspy breathing penetrated harshly through the serenity of the moment. Like a good medical student, I set to task repeating the neurological exam, looking for any differences from the morning. Dolls eye test. Corneal reflex. Tap on the tendons. Check tone. It is just as I remove her sock to perform a babinski exam that I notice a subtle change in the room. It takes me a moment to realize that the throaty death rattle, my patient's weakened attempts at oxygen exchange... had stopped.

The first thought to race across my mind was "Oh shit!" I don't know how, but I remembered at that moment her do-not-resuscitate status, which fortunately prevented me from running into the hallways like an idiot yelling "Call a code!!!!" I watched as the color rapidly drained from her face, and stepped out of the room to talk to the nurse. "Ms. R just passed away. I don't know the protocol for the hospital, do you need to page the attending? I'm just a medical student." She replies that it is ok, as the patient was on comfort care. "Just go listen to the heart and lungs to confirm."

As a medical student, you are not trusted to do a whole lot. In today's chaotic environment of CYA-medicine and medical malpractice, we mainly pretend we can do things while someone holds our hand, until intern year rolls around. And a task as simple as listening to a patient's heart & lungs and feeling for a pulse should be elementary for a fourth year medical student, who has felt hundreds of pulses and listened to hundreds if not thousands of hearts. Regardless, there was a certain amount of anxiety involved in confirming a patient's death. Placing a finality on a life, even a life known to be near it's end, felt like a heavy responsibility. "I'm just a medical student."

"Time of death 18:21."

There would be no code, no crowd of people in the room, no blood staining the gown from STAT blood draws. Just myself, and my patient - a patient I had never even talked to. This was a different death than what I was used to. Some would say a good death. But the intimacy of the moment, especially considering it happened while I was performing the physical exam, struck me.

I page my neuro attending to tell him the news. He breaks the mood with some levity: "Well don't go see of the other patients now... I thought they were supposed to be healing hands!"

I looked down at those healing hands.

Onwards and Upwards

Jeesh, I've been really slacking on this blogging thing. Probably because my life has been incredibly uninteresting the past month slaving away in honor to the boards gods. So I successfully (I think) navigated the travails of Step 2 and its assorted clinical vignettes and fake patients. The second romp with the Step exam was not nearly as stressful or interesting as the first go. More a matter of knowing what you have to do, then going and doing it. And yes, Step 2 CS is as big of a joke as everyone makes it out to be.

This month is neurology, which has turned out to be a quite the neurocation. Which means I've replaced qbank and first aid with monday night football and hulu. I'm already starting to feel that 4th year senioritis sink in.

First residency interview invite finally trickled in today. The residents warned me that in ENT things happen late, so while my classmates have been racking in the interviews I've been obsessively checking MyERAS to see "Available, but not yet retrieved" over and over again. After a month of hearing only crickets, it's nice to finally start getting some movement. So it's back to twiddling my thumbs and hitting refresh on my cell phone email every 30 minutes.

Btw, blog crossed 50,000 visitors this week. Pretty freaking surreal if you ask me. Thanks to all who follow this site and pretend to enjoy the content. Never thought when I started this thing it would generate such attention. Y'all are great!

Retro

So this month has been a blast from the past. Like all fourth year medical students in our fine nation, I've been spending the past week buffing, fluffing, proofreading, and shining my residency application. It brought back many a "fond" memory of 2006 when I was going through a similar process applying to medical school. And just like before, I'm stuck in that weird limbo now where everything is submitted, there's nothing left to do, and now it's a matter of waiting, and waiting, and waiting. As someone whose past four years have been filled with things to plan, things to do, things to prepare for... it's a strange feeling.

"Fortunately" I have Step 2 to keep me busy this month, which involves plenty of QBank and First Aid. It brings back many a "fond" memory of 2009 and preparing for Step 1. Luckily, none of the same anxieties this time around. But I'm back to my favorite spot at my favorite Starbucks, highlighters in hand. God knows how I did this for two whole years.

Luckily, only another 10 days of this then I'll literally be out of things to do. Who knows what I'll do then, I sure don't.

Empathy, Tragedy, and Progress

She was 28 years old when she first noticed the spot on her tongue.

Red and bleeding, it resembled a pinpoint ulcer along the left lateral border. She went to her doctor, with understandable concern. And he reassured her it looked like a small aphthous ulcer. He told her if it did not get better, or got larger, to come back and see him.

Shortly after that, she became pregnant with her third child. And as anyone would in that situation would likely do, concerns of small aphthous ulcers were placed into the back of her mind as her and her husband went about planning the new addition to their family. Months went by, until one day in her third trimester, she was brushing her teeth and noticed blood on the toothbrush. She took a look at her tongue again, only this time to find a large hard mass in place of the small red spot from before.

What followed was more doctors visits, biopsies, referrals, and a diagnosis... squamous cell carcinoma of the left lateral tongue. She was told there would need to be surgery, but not for another few weeks until her baby was safely delivered.

The baby was safely delivered.

It was the morning of her operation when our paths first crossed. I introduced myself to her, and the entirety of her large, supportive family in the pre-op room. I made small talk, and she spoke in articulate words with a slight British accent. I asked if she had any questions, and she shook her head no.

Back in the operating room, it was business as usual. Help transfer the patient to the OR table. SCDs on. Bovie pad on. Extra blanket on. Warm air circulating. She succumbs to the general anesthetic. Intubation successful. Rotate table 180 degrees. I go out to scrub with the attending and resident, yellow iodine dripping down my forearms into the sink. Sterile towel. Sterile gown. Gloves. Spin. Prep the operative field.

We are finally ready to begin, and we finally get a good look at the tumor. It it large, extending from the lateral edge nearly to the tip. Fingers of white parasite extending deeper into the tissue.

Calmly, the operation commences. According to the pre-operative MRI, it looked like the tumor did not creep too deep. The hope was to get in, get clean margins, and close primarily, leaving her enough residual tissue that her speech and swallowing would be largely unaffected. The dissection proceeds around the mass, and finally the bovie tip penetrates out the opposite side. Frozen sections are sent off to pathology, and we breathe a sigh of relief for the moment. We sit and absorb ourselves in the BB King playing from the iPod. We have a discussion about how much we enjoy the blues.

The phone rings, pathology on the other end. "Frozen sections show margin passing through tumor." In the passing 3 hours, more tissue was taken, more sections were sent, more phones ring, and more swear words penetrate the soft, solemn blues of BB King wafting through the air. The partial glossectomy transforms itself into a hemoglossectomy, which creeps towards a near total glossectomy with each positive margin. Finally, margins are clear and we close, folding the thin strip of remaining tongue over onto itself and securing it with the appropriate number of half hitches.

I am reminded on my last question to her before the operation, when she simply shook her head and smiled. What brings me back to that moment is that for the next few days, her sole mode of communication involves those same left-right, upwards-downwards motions. Any pain? Shake no. Comfortable? Shake yes. Ok, more of the same today. Try to get out of the bed. She turns out to be quite lucky in some ways. Her swallowing was intact. And she will eventually speak again, though not without a heavy lisp and not until the burns of the radiation therapy subside and many months of speech therapy are completed.

There were two things that stuck out to me as particularly profound about this case, about this mother of three.

First occurred during those nauseating hours in the OR as frozen section after frozen section returned with tumor as we burrowed deeper into tongue tissue. With each subsequent resection, I could not shake the feeling of how horribly I felt for the patient, that we were slowly robbing her of her chance at a normal life. Part of that is good, I think. It means these past four years of medical school have not robbed me of those intimate emotions, of the ability to feel empathy for the person prepped and draped in front of me. But I was also struck by how calmly and confidently the attending surgeon, a man I greatly respect and admire, went back to work with each setback... steadfastly marching with tenacity towards negative margins. He knew the data, but more importantly he had lived the data in his many years of practice. He knew that if we did not get clear margins, this woman in front of us would be robbed of her chance to see her children grow old. So he could bury those emotions in order to do what is necessary. Me, I could not yet detach myself from those feelings of horror, because I was not yet convinced it was necessary. Quite bluntly, I have not seen enough people die to be convinced.

It reminded me how much time and space still yet separate myself, inquisitive pitiful fourth year medical student, from the title of surgeon. Because in that situation, I'm not sure I could have done what was necessary. That was humbling to realize.

The second profound moment came the next week in clinic when the attending, chief resident, and myself saw the name of a 32 year of woman on the schedule for follow-up. She too had developed a tongue cancer noticed after becoming pregnant. She too required an operation and radiation. We got to talking, and the chief resident remembered another young woman from her second year of residency who had a tongue squamous cell. We look at her chart and notice she was pregnant. "Interesting," the attending states, and we go to see our follow-up patient. Somehow the conversation turned to what we were discussing earlier, and the patient states she also knew another young woman in the south part of the state who had tongue squamous cell. The momentum of the conversation between the three of us accelerated throughout the day. By the end of clinic, we had assembled a list of 9 young pregnant women with tongue cancer who had been operated on in the past several years. Questions floated about to the tune of the scientific method. Why pregnancy? Why are we seeing more of these tumors? What's different about these tumors? Are there unique ways of approaching treating them?

And so a hypothesis was born. And a plan. There would be a study. IRB protocols and special stains and information databases and eventually a publication. And hopefully... progress. And I thought that all is not so horrible after all.

She's high maintenance.

There's a dangerous new mistress in my life that's been sucking up all my time I would have been writing on here, and her name is "ERAS". I know, sexy.

Anyways, promise more stuff is coming soon.

Sub-I... Check.

Man, time flies when you're having fun, I guess. My four weeks on my otolaryngology sub-i were over in a flash. I have to admit, I was a bit nervous coming into the rotation. I felt like I had a fair amount of exposure to the field of otolaryngology, but any time you're making a decision to enter a field when you haven't spent dedicated time rotating through the specialty, you have to wonder if you'll end up enjoying it as much as you think you will. Luckily, I found a great experience during my rotation that reaffirmed rather than undermined my decision.

That being said, talk about a crash course of an experience. Doing a sub-i in a field that is only peripherally covered by the third year rotations, I found myself having to read quite a bit every night just to stay on top of the topics I may see in the clinic or OR the next day. Luckily, I got to rotate through a different service each week, so I could focus each week on learning one specific aspect of the field, be it head & neck, rhinology, peds, or facial plastics. That being said, I felt like the rotation was much less about showing what I knew and much more about showing my willingness to learn. Definitely a different experience than some of my friends who were doing sub-i's in general surgery, internal medicine, etc where you're expected to have mastered basic principles as a third year and graduated on to more patient management.

That being said, being a sub-i kicks butt compared to being a third year. The attendings know you are entering their field, and are much more willing to tolerate your presence and teach. You're given more hands-on opportunities. You're seen more as part of the team and less as a stranger passing through for a few weeks. Good times abound.

Some highlights from the four weeks:
- First assisting an entire anterior lateral thigh free flap
- Getting to perform a trachesotomy on my own
- Pulling a popcorn kernel out of a 3 year old kiddo's ear
- Draining 350cc's of pus out of a patient's neck who has a post-op infection (I'm afraid to admit... I love I&D's)
- Becoming known as "the PEG man" on service, and being paged specifically to come put one in
- First assisting an entire rhinoplasty with rib cartilage harvest
- First time getting to use the microdebrider
- First time getting to play with the DaVinci robot
- First time getting to shoot the laser

But, all good things must come to an end. My sub-i wrapped up and now I'm off on an away rotation. Living in a different, large city with only a small furniture-less room and a twin sized bed to call home. But still otolaryngology, so I can't complain. Grin.

Reflections on Third Year

So third year ended 2 weeks ago for me, and I've yet to write about it. You think after an "accomplishment" such a surviving third year I'd be bursting with feeeeeelings about the matter. After all, I briefly delved into the realm of the introspective when I finished first year, and I got damn near teary-eyed after taking down Step 1. After third year, I don't know. I don't have that same sense of accomplishment, and the same sense of transitioning onto something new. Am I glad I no longer have to rotate through specialties I have no interest in showing faux-interest along the way? You betcha. But I didn't wake up the day after my OB/Gyn shelf feeling any older or wiser. I think part of that is because the transition to the next level of competency tends to come throughout third year rather than after it. Before my last shelf exam, I was thinking a lot about my first rotation on peds and the student I was then was very different from the student I am now. But that change was a slow process that had little to do with the MS label after my name. Basically, I can see the progress I made this year, but don't really feel like I "survived" anything. Maybe it's because I really enjoyed third year and the things that are historically dreaded about it weren't that big of a deal to me. Maybe it's because I'm going into a surgical field and I know my days of sleep deprivation, early mornings, and busy days are far from over. And you know what, I'm cool with that.

That being said, good riddance to the third year label. It'll be nice to not have people automatically assume you know nothing and can do nothing just because you're a third year medical student.

Anyways, it was a good week off, and now I'm on to the greener pastures of fourth year, the "best year of medical school."