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Hospital Sushi and the Five Stages of Grief

 

Prologue

It’s 1:30 PM on a beautiful Saturday afternoon. You’re on call, and hungry, and having not had the forethought to make food ahead of time, you decide you’ll take your chances and see what the hospital cafeteria has to offer. You bustle your way past screaming children, harried caregivers, and distracted hospital staff with their heads buried in smartphones, following signs for the fork and knife.

Finally, you arrive. After considering the stack of soaking wet trays to your left, you decide to forego this piece of gastronomical technology. You’ll rough it.

The room before you does little to whet your appetite. A smell of fatty decay and sweet sepsis wafts through the cafeteria. It is a hospital, after all. Although ostensibly well lit, the room is actually somewhat dark. The fluorescent lights tasked with illuminating the room emit weak, yellowish, lazy blobs of haze that seem to quit about a foot away from the bulb. But you’re hungry, and light or no light, you’ll have to find something to nourish you.

Suddenly, you see it. A large wall-based refrigerated display case. In it are various “healthy” pre-wrapped foods bathed in crisp white lights. This is the land of salads and yogurts. Of apples and ham sandwiches. Of — could it be? — yes — sushi. Hospital sushi.

I. Denial

“No, no. This can’t be right. There can’t be sushi here,” you think. “This is a hospital. It is a building filled with people that die from horrible bacterial infections. Bacteria like Salmonella and E coli. Resistant super-bacteria like methacillin-resistant Staphylococcus aureus, vancomycin-resistent Enterococcus, and multi-drug-resistant Pseudomonas aeruginosa. Why would anyone in their right minds put raw fish in a place like this?”

You instinctively walk away from the refrigerated display case. “No, no” you keep muttering to yourself. “It can’t be.” Your legs carry you away faster than you expect. You wind up in front of the American Classics section of the lunch line. “Finally,” you think, “some sanity and order. I’m getting pizza.”

II. Anger

You inspect the pizza more closely as it rotates in a glass display case that was last cleaned by an industrial revolution era British chimney sweep. The cheese drips off in uneven glops. The crust comprises fully half of the surface area of the pizza. You see a solitary piece of pepperoni dangling from the edge of one of the slices, wishing it’s life away as it stares into the abyss. You feel solidarity with the pepperoni. Your heart sinks.

Your gaze turns down the aisle, to see what other American Classics might entice you. It’s slim pickings. There are several unattended serving stations with steel serving trays of water simmering gently. A pile of chicken wings catches your eye, but so does the ocean of oil that it is currently buoyed in. How difficult would it be to get actual food in this place, you wonder, half-aloud.

Your phone vibrates. You pick it up. It’s a facebook notification. Your friend Taylor just posted a picture of a bowl of ramen, two tall glasses of beer, and an inviting, sun-lit outdoor restaurant. “I love saturdays!” she exclaims virtually. Your blood pressure begins to rise, and you hear the faint rumble of a train engine. You never considered how wise Emperor Palpatine was when he mentored Anakin in the Star Wars Prequels. You feel the hate flowing through you.

III. Bargaining

You turn back to the sushi. Sushi, a delicate culinary art. A masterpiece of local cuisine. The pride of a nation. The height of sophisticated, savory splendor. “It’s trapped,” you think to yourself. You begin to feel sympathy for the sushi. After all, it didn’t decide to reside in this grotesque carnival of inedible calories. It was brought, against its will, to this horrible place.

“Maybe,” you think, “if I purchase it, I will send a message to the establishment. I’ll make a statement that, while I agree in principle with what this food stands for, it makes absolutely no sense to serve raw fish in a hospital full of bacteria. I support the concept of this type of food. If I buy it, I’m laying the groundwork for change.”

You pick up the tray of sushi. Salmon avocado. It’s $8.99. The pizza was $2.99, but you just can’t bring yourself to go back. Some things can never be unseen. You desperately hope that the pepperoni is still hanging in there, still fighting, but you can’t bring yourself to look. You can’t imagine what that little pepperoni has been through.

IV. Depression

You walk to the check out counter. “Just the sushi?” the clerk asks. “Yes,” you say, “I would like to have this raw fish, please.” Behind you stands a man with an IV pole. His foot is heavily bandaged. The smell emanating from the bandages would have been fairly effective as a nerve gas in the first World War. Your mood sinks.

You walk to an empty table, and open the sushi tray. You remove the Green Plastic Plant-Like Divider™ that separates the sushi from the soy sauce. You open the soy sauce, but in doing so squirt some on to your (formerly) white coat. Another casualty. You unsheath your chop sticks. You breathe deeply, but are instantly reminded by your olfactory bulb that you are in a building where people consistently die.

V. Acceptance

Chopsticks quivering, you reach down to pick up the first piece. You can see it fully in the light now, and you note that there is actually more salmon there than you first thought. You muse briefly on how you’ve been to sushi places before that were more stingy with their fish rationing.

The first bite. You chew apprehensively. You swallow. Slowly, very slowly, you realize that you are enjoying it. The salt interacts with the raw fish beautifully, unlocking its flavor. You are dumbfounded when you realize you’ve had worse sushi than this before. You go in for the second piece, then the third. A helpful pile of ginger allows you to reset your palate, making the fourth piece seem like the first all over again.

You finish your sushi. The ginger and wasabi work wonders in blocking your nose’s receptive capabilities. Suddenly, a thought begins to blossom in you. Bigger and bigger it grows. It enters your conscience with force and you stand suddenly, asking yourself —  Am I full? 

You walk back to the display case. There sits another one. Salmon Avocado. You pick it up. It’s still $8.99. You turn it back and forth, examining its contents through the clear plastic. You decide you’re mostly full, and put it down. You walk away from the cafeteria, the salmon flavor still dancing over your taste buds. I am content, you think. I am full.

Exciting Developments

Hello everyone!

I’m very excited to announce that my writing will now be featured regularly in the Houston Chronicle! I’ll be writing a column called On Call in the local section for Gray Matters, an ‘Intellectual Life in Houston’ blog. My first article just went live today, about a son coming to terms with the impending loss of his father:

http://www.houstonchronicle.com/local/gray-matters/article/Mr-H-was-dying-His-son-couldn-t-stand-it-11230874.php

Since my writing for the Chronicle will mostly focus on patient stories, I will try to to use the blog more for humorous pieces. I could also explore writing outside of purely medicine. If you have any suggestions about what topics you’d want to see, please comment or get in touch with me!

Thanks everyone!

-Ben

Memories of Grace

I think it’s fair to say a small part of all of us died along with Grace McDermott. Grace was a beautiful, talented PhD student studying in Ireland who tragically passed away in a house fire this past week. She was many things – musician, blogger, extrovert, women’s rights activist – but she was also my first girlfriend. I’m still in shock.

It’s hard to comprehend something like this. The mind shudders and reels, seeking to find meaning but failing. Something went wrong in the universe. I first heard on Tuesday when a member of the youth orchestra we both played in, The Metropolitan Youth Orchestra of New York, messaged us the horrifying news. I spent that day in a daze, breaking down that evening, crying for hours.

Grace and I met on a MYO summer musical tour of China. She was a singer, I was a horn player. She confidently walked up to me after the first rehearsal, looked me in the eye, smiled, and said “Hey! I’m Grace. I like your sandals.” As an incredibly awkward high school junior with the romancing skills of a calculator, this felt something like winning the lottery. Not quite believing my luck, I somehow managed a reply, and in a few weeks we were dating.

We dated for about a year, breaking up as I went off to college. We didn’t stay close, but though I hadn’t spoken to her in almost 10 years, I enjoyed every time she popped up on my facebook feed. She’d like a post of mine, I’d like one of hers. We’d comment on each others blog. She was thriving, the world slowly but surely becoming enchanted with her passion and wit.

The memories I have of Grace are fleeting, but vivid. Around and around they swirl now, unattached to any living person. Half of a memory. I remember the way she would run and jump into my arms when she saw me. The way she would cock her head slightly when she was about to sing the first note of her aria. The way you could tell whether or not she was really laughing by an infectious, cackling glee that seemed to fully infuse itself in her body. The way she would designate something as enjoyable: “It’s – ,” followed by a dramatic pause, then, “sooooo goood.”

Grace taught me true, unbridled love. She had a clear vision of what she wanted, and she pursued it. This became immediately apparent on the plane ride from Detroit to Beijing. I had known Grace for about a week at this point, and I again couldn’t believe my luck when I realized that Grace was sitting directly next to me on the flight. We watched movies, listened to each others music, and talked about whatever it is that 16 and 17 year olds talk about. She eventually fell asleep on my shoulder. I remember looking around the airplane, surrounded by snoring American and Chinese travelers at 4:00 AM, thinking I don’t think it gets much better than this. I later found out that Grace had engaged in a shadow campaign to figure out what seat I was on and switch seats so she could be next to me without me knowing. You can’t not fall in love with someone like that. You just can’t.

When tragedy strikes, it removes a filter I live with on a day to day basis. Gone is the delusional haze of banality that normally fogs my thinking. Oh yeahI remember. Life is fucking arbitrary and unfair. Perhaps it’s a defense mechanism, and I just can’t handle the two-faced nature of reality: potently meaningful, crushingly insignificant. But even with the filter gone, I still couldn’t understand what had happened. The only thing that made sense was a mantra from my clinic attending which I kept repeating over and over in my head: young people shouldn’t die.

The international outpouring of grief, shock, affection, and love for Grace wasn’t by accident. She had qualities that people recognized instantly as genuine. She was honest and engaging. She was funny and intelligent. She did what she felt was right. She lived with intensity.

In whatever feeble capacity I have to fight against the injustice and randomness of it all, I want to honor what Grace stood for by trying to be more like her. She taught me how to love someone. She focused on the things that mattered. She was that rare being that inspired those around her, and made things better.

Goodbye Grace, and thank you for changing my life.

The Biker

A lone figure stood at the entrance to Bed 14, Intensive Care Unit 2, Floor 15 North. Though it was 2:30 AM, he stood at rapt attention. He looked out over the hallway, eyes scanning. He looked not unlike a gargoyle brooding over his castle, protecting it.

He looked unlike anyone I’d ever seen in an ICU. He was a slightly pudgy yet wholly muscular 5′ 10” or so, with a few days worth of stubble, a handlebar moustache, and a tight buzz cut. He looked to be in his early forties. He wore a thick black leather jacket emblazoned with a large “ORIENT: HIGH PERFORMANCE” patch on the back in bright yellow. From his jacket elbows dangled two large elbow guards. In one arm, he held a large white motorcycle helmet with a black visor. Around him, various family members streamed in and out of the room.

The man lying in Bed 14 had arrived to the unit several hours earlier in respiratory distress. We started him on BiPAP, an oxygen mask that pushes air into your lungs during inspiration and keeps them open during expiration. It’s uncomfortable, but it’s effective. After only a few minutes he was breathing more easily. He couldn’t talk that well after we started BiPAP, so I had to ask his sister for the story. The man with the motorcycle helmet stood outside of the room, listening.

The story was devastating. I knew before I asked. Families that have battled it out with chronic diseases over long periods of time have a hardened, steely look to them. Not this family. Their eyes were too wide, too disbelieving. Not good.

His sister told me that he had noticed a worsening cough over the past three months. Some fatigue, some shortness of breath. Most damningly, he’d lost 30 pounds since he noticed the cough. Then he started coughing up blood, and came to the ER. That was five days ago. The CT scan of his chest and abdomen was almost a formality. He had widespread, incurable cancer. It had exploded across his lungs, liver, spleen, bones, and brain in a few short months. The only treatment options available started with the word “palliative.”

The patient and his family knew this already. But now they were in the ICU, where sick patients die. I explained that intubation was the next step after BiPAP if he failed to improve. I explained that multiple organ systems were failing simultaneously due to the high tumor burden: his kidneys were turning off, his blood was clotting, his heart and liver were showing signs of injury. After talking with the family some more, I left the room.

An hour or so passed before I made my way back to bed 14. But before I could enter the room, the man with the motorcycle helmet stopped me in the hallway. He looked into my eyes with an intensity best measured in horsepower.

“Do you have a brother?” he asked.

“Yes, I do,” I replied. “He’s my best friend.”

He nodded, then turned to look at his brother, weakened and dying. He seemed to be saying: so you know what I’m going through. A lump started forming in my throat. I wasn’t ready for how direct he was being with me. I have a brother. What if something happened to him?

“The fucker in that room saved my life.”

“What do you mean?”

“We were never that close. He was always ‘go, go, go,’ I was the opposite. He got good grades, pushed himself, started his own real estate business. I was a fuckup. Eventually I got my EMT-B, joined the army as a medic. I was deployed for 9 months in Afghanistan. Fucked me up. Thought about suicide a bunch of times. I don’t know why, but I called him. He talked me out of it. Told me to get help. I’m on meds now, see a shrink.”

He paused, and started inspecting his helmet. I could see our distorted faces in the reflective curvature of the visor. He turned to look at his brother, then looked at me again. “It’s hard for me to see him like this,” he said. I nodded in agreement.

I continued into the room. The man with the motorcycle helmet kept watch from the hallway.

My shift ended at 7 AM, and I went home. But the interaction stayed with me. I kept thinking I have a brother, I have a brother. I wondered what had happened between these two brothers to cause such distance. What was that phone call like? I have a brother. How would I react to a family member’s imminent death?

We ask a lot of questions as physicians, and we answer a lot of questions. But not usually about ourselves and our feelings. The man with the motorcycle helmet exposed something in me: I don’t know what watching a loved one die is like. He asked me to try to imagine his scenario, and I did, however briefly and incompletely. I felt fear, helplessness, despair.

But I also felt something else. I’d gained an understanding of the man in bed 14. He was the hero of a story I’d never read. In the end, he had accomplished something no doctor was able to do for him. He’d saved a life.

Running My First Code

“CODE BLUE, 7 SOUTH. CODE BLUE, 7 SOUTH.” I’m up and out of my call room bed before fully regaining consciousness from my light sleep. It’s 4 AM. I should feel ready: I’ve trained with simulations labs, mock codes, and test questions. I passed my CPR and ACLS courses. I’ve done chest compressions as an intern. But this is different. I’m the resident on call, and if I get there first, I’ll be running the Code. I’ve never run one before. I’m terrified. I’m not ready.

Code Blue is essentially a euphemism for being dead. While it technically means “medical emergency,” it has come to mean that someone in the hospital has a heart that has stopped beating. The outcome statistics are grim. Even with perfect CPR, in hospital cardiac arrests have a roughly 85% mortality. Those that somehow survive are often left with irreversible brain damage and lie in comas. Few ever leave the hospital. Death is greedy.

Still, we have to try. I run down the corridor towards the patient’s bed. My sneakers make little squeaks against the linoleum floor, echoing off the walls of the mostly quiet hospital. My mind is a zoo. The flooring makes this place sound like a gymnasium. How many minutes in between epinephrine injections again? I should run more, I’m already out of breath.  Think of causes, causes. The 5 H’s, the 4 T’s. What was the room number?

I burst into the room, out of breath. It is pure, primordial chaos. I’m hit with the sound first. Bed alarms, blood pressure alarms, and heart rate alarms blare insistently, a Greek Chorus to the unfolding drama. An unanswered, continuous string of questions hangs in the air like a heavy fog. “Can someone page anesthesia?” “Where’s the cards fellow?” “Do we need femoral access?” “Where’s the EKG?” “Chest X ray stat!” “Who spoke to the family?” “Is this guy DNR?” “Who has a hemoglobin?” “Is he on blood thinners?” “What’s his history?” I can hardly hear myself think. This must be what being in the cockpit of a nosediving plane is like. 

I take stock of the room. One nurse is on the bed, performing chest compressions. A second is trying to steady the man’s arm to place an IV, but is having a hard time. A third is struggling to hold an oxygen mask to the man’s face while squeezing an amboo bag. Pharmacists are rifling through a large red chest of medications. Someone is desperately clicking at a frozen computer in the corner of the room. A gaggle of nurses, aids, and respiratory therapists stand at the door.

The patient is staring straight at me. His eyes are glazed and unfocused. He’s an older white man with a shaggy beard and sunken temples. His skin is a uniform, mottled blue-grey. His head flops every second or so from the force of the compressions, and currently he’s turned to face the door, looking at whoever crosses the threshold.

I take a deep breath. “Is anyone running this code?”

There is only silence. Beautiful, terrifying silence. No one is standing at the foot of the bed, which is where the code leader would normally stand. I’m going to have to run it. It’s only a second or two, but the moment stretches and stretches. And seconds matter.

The brain is the most adaptable and responsive piece of biological engineering we know of. It responds in real time to the binary input of billions of neurons to create sight, sound, and sensation. It can accommodate elevation changes, pH changes, temperature changes, volume changes, infectious states, starvation, and fight-or-flight responses. But it has an insatiable demand for oxygen. There is no safe-mode, no low power state. Four minutes without oxygen destroys seventy-six years of life. Here we go.

“I’m Dr. Gold, I’m leading this code. You, keep time. You, continue compressions. Let’s hook up the pads. Draw up one milligram of epinephrine…”

The training kicks in hard.  Good hard chest compressions, with epinephrine every 2-5 minutes. Pulse checks every 2 minutes. Shock the heart if it’s ventricular tachycardia or ventricular fibrillation – a call that will be made by me. I hear a faint crinkling sound with every compression. Ribs breaking. Then a voice: “2 minutes, doctor.”

“Pulse check!” The compression stop. Hands immediately reach for the femoral and carotid arteries, straining to feel the reassuring rhythmic pulse of life. All eyes turn to the cardiac monitor. It’s hard to interpret while compressions are going, but now it’s clear. The heart’s electrical system normally conducts each beat with fanatical precision:

Now it is in disarray, starved from a lack of oxygen:

 

It’s V-Fib. Disorganized, random electrical discharge that is unable to produce heartbeats. “It’s V-fib.” I say it quietly, almost to myself. No one moves. “V-fib,” I say again louder. Still nothing. Why aren’t they moving? Oh, right. They’re waiting for me to say something. “Continue compressions. Charge the defibrillator. We’re going to shock.”

We shock. The patient’s body tenses suddenly and violently. It’s strange to see him move so much. Strange that our muscles run on electricity. Strange that to save someone you hook them up to an outlet. We’re more machine than we realize. To reset pacemaker: turn it off, turn it on, see if that helps.

We continue CPR. Anesthesiology comes and inserts a tube into his throat so we can breath for him. But it doesn’t matter. We never get another shockable rhythm after the first shock, just a flat line. Asystole.

More compressions. More epinephrine. Other meds, too: amiodarone, calcium, magnesium, bicarbonate. We draw quick-resulting labs. We call cardiology for a bedside echocardiogram to look at the heart. It’s not moving at all. After 30 minutes, I ask if anyone has any objections to stopping the code. No one does.

We pronounce him dead.

And just like that, the mayhem ends. The compressions stop. The plastic IV tubes are disconnected and thrown out. The hastily placed endotracheal tube is removed. The alarms are silenced. The defibrillator pads are removed. Pharmacy takes their cart of medications and leaves. The crowd begins to thin.

The patient’s nurse begins making the final arrangements before the family arrives. His jaw, which was slightly gaping, is gently closed. His head is laid straight back, eyes looking up. Bloody linens are replaced with fresh ones. The patient is draped in a new gown.

Despite his recent ordeal, the patient now radiates a sense of calm. The man’s stillness is serene, otherworldly. Impossible for a living being to achieve. The few remaining people in the room use hushed voices. The room feels sacred, somehow. I look at the man again. I think of Homer’s line from the Odyssey: “Upon his eyes gathered the mist of death.”

I perform the death exam. I check his eyelids and see no corneal reflex. Feel no pulse. Hear no breath sounds. It’s done. I exit the room.

A few feet from the door, a young black woman in cheery pink scrubs is curled up in a ball on a rolling chair near a desk. Her head is in her hands. Her shoulders jerk intermittently. In printed block letters, her ID badge reads MEDICAL VOLUNTEER.

I ask if she’s OK, and she looks up at me. Her eye shadow is starting to streak down around the corners of her eyes.”I was watching him. I – I called for help. He wasn’t breathing. I’ve never seen… that… before.”

I nod. Words don’t come. I stand beside her for a while. After a few minutes, I turn and head back to my call room. Somehow, I feel comforted by her crying. This seems the most appropriate reaction to the last thirty minutes of anyone.

I’ve run a few more codes since this one. It feels, if not routine, certainly easier than the first one. More algorithmic. But I can’t shake the feeling that I shouldn’t become too comfortable doing this. I want to always remember that volunteer. She didn’t know this patient personally, it wasn’t family. But she wept all the same. To me, her tears acknowledged the frailty of it all, the randomness. The callousness of death, the gift that is life. It was inspiring. The day I can’t feel the way she does about my patients is the day I need to find a new profession.

Medical Codes, Explained

Hospitals have lots of codes. The most famous one is Code Blue (medical emergency), but it turns out there are lots of color-based codes. This can be confusing, as the connection between the code colors and the situations they represent are usually tenuous at best. Today we explore all of the types of codes, and shed some light these arcane medical euphemisms.

 

CODE BLUE

What it sounds like it means: Aggressively-scented cologne from Armani.

What it actually means: Adult Medical emergency, CPR response team required

Medical Perspective: Someone is (technically) dead, and we are going to try to make them not dead.

 

CODE RED

What it sounds like it means: Xtreme Mountain Dew energy drink

What it actually means: The building is on fire

Medical Perspective: I’m completely at a loss on this one. Why not just call it a fire? Who are we protecting by changing the name? Code Red, Code Red, everyone evacuate the building so your body doesn’t catch on code red. Hey, when this is all over, let’s all go back to my place and roast marshmellows over a nice cozy code red!

 

CODE GREEN

What it sounds like it means: San Francisco based education startup that teaches children C++ and Java while instilling in them the values of environmental stewardship and conservation. The kids help write software to run large wind turbines, which in turn power the computers they learn on.

What it actually means: Behavioral emergency

Medical Perspective: These can get weird. I once had a patient threaten to summon a meteor ‘the size of Texas’ to smite me.

 

CODE ORANGE

What it sounds like it means: What the leaders of every other government in the world secretly whispered into their headsets on November 7th, 2016.

What it actually means: Hazardous material spill

Medical perspective: “Isolate and evacuate,” which is the official tagline of hazardous spills, is also how most Americans felt on November 7th, 2016. Also, much like a hazardous material spill, our president-elect will likely ruin everything he touches.

 

Code Pink

What it sounds like it means: This one is really sad.

What it actually means: Infant abduction

Medical perspective: Ugh. I can’t think of anything witty. Infant abductors deserve life sentences.

 

Code Grey

What it sounds like it means: When Anderson Cooper brings the thunder. He is Zeus, and probing, hard-hitting questions are his lightning bolts.

What it actually means: Loss of essential services / infrastructure failure

Medical Perspective: Again, seems like we are unnecessarily steeping ourselves in mystery here:

“Code Grey!”

“What?”

“Code Grey!!”

“What the hell does that mean?”

“Loss of essential services and/or infrastructure failure!”

“What?”

“The basement’s flooded and the computers are down.”

“Why didn’t you just say that instead?”

“No time!!”

“Why?”

“GET YOUR HEAD OUT OF THE SAND!”

 

Code Black

What it sounds like it means: If Michael Bay ever got creative control over the James Bond franchise, there’s an 85% chance this is the name of the first movie.

What it actually means: Bomb threat

Medical perspective: If a doctor ever describes themselves to you as being “the bomb” at their procedure, go with a different doctor.

 

Code Purple

What it sounds like it means: Project Runway-style fashion show on Bravo where a team of style experts are dispatched to people’s houses 30 minutes before a major social event to spiff up their look.

What it actually means: Hostage situation

Medical perspective: [Code Purple team, to disgruntled patient]: “Trust me, I’d be desperate too if I had to wear that hospital gown a second longer than I had to.”

 

Confronting the Devil’s Army

The ER doc sounded genuinely concerned, which is never a good sign. “Sixty-year-old guy, no real medical history, dude is seriously hallucinating. Head imaging is negative. Can you come take a look at him?” I flitted through the chart. A car accident a few years ago that left him with chronic, poorly controlled migraines. Depression, on Prozac and well controlled. That was pretty much it. I grabbed my stethoscope and headed down to the ER.

I opened the patient’s door, and stepped into a scene of biblical intensity. The man before me was frantic, gesticulating wildly with his right arm and clutching a small white bible with his left. He had a noble, square, clean-shaven face with a shock of white hair and a pair of thick-framed glasses riding somewhat unevenly across his nose. His eyes were everywhere: first to me as I walked in, then to his wife, back to me, then away, his gaze darting and dancing across the room.

I walked over to his side. I introduced myself, extending my hand to his. He grabbed it and held it, clutching the tendons of my hand as if they were a life preserver. “Doc,” he said in a stately, somber baritone, “they’re everywhere.” “Who?” I said. “The devil and his army,” he said plainly. “They’re everywhere. I see them, I see.” He voice was honest, earnest. He put special emphasis on certain words. “The great red eye. The great de-ceeei-ver. You’ll have no power over me, you hear? You have no power, Satan. You see? No power here.”

I asked him how long he’d been seeing this. “For about…about a year. Yes, a year. A year of marching, a year of the red flame…” From the corner of my eye, his wife slowly shook her head ‘no.’ After I examined him, I stepped out of the room with his wife. “It’s the craziest thing, he was totally normal yesterday. Then, all of a sudden, at around midnight, he woke up from sleep and started waving his arms, talking about the devil.” “Is he very religious? A pastor, Sunday school teacher?” “Nope. Truck driver. He was raised protestant but we’re not particularly religious.”

After obtaining the rest of the history from his wife, I went back into the patient’s room. Once more, I held his hand. “I’m not sure what’s going on. But we’re going to get to the bottom of this. I’m going to admit you to the hospital for the next few days. Hang in there.” He looked back up at me. “Please, doc. Help me.” I headed back to my team room.

The man’s hallucinations were extraordinary for their timing. People in their sixties don’t usually wake up one day seeing things that aren’t there. Sudden changes in perception usually indicate extrinsic circumstances like drug use or extremely traumatic events. Our patient had neither. He also had no signs of prior mental illness besides his depression. If our patient had a longer term thought disorder, we’d expect more clues in his history. Years of hallucinations, extensive psychiatric history, and antipsychotic meds would all be documented in the chart. But there was nothing. I sat in a frustrated silence in my team room. What the hell was going on?

I ordered the basic set of labs that most patients get upon admission to a hospital. These include sodium, calcium, and glucose levels. Fluctuations of these chemicals in the body can cause mental status changes – perhaps they were the culprit. I ordered a vitamin B12 level, a rapid plasma reagin test, and a thyroid stimulating hormone level. A B12 deficiency can cause neurological changes. The rapid plasma reagin was to test for syphilis (which can affect the brain in untreated chronic cases). Thyroid stimulating hormone levels would tell me if he had an underlying thyroid condition potentiating his psychosis. I also ordered urine studies – sometimes urinary tract infections can cause altered mental status.

By the next day, all my labs had resulted. Everything was stone cold normal. No vitamin deficiencies, no latent infections, no electrolyte abnormalities. Hmmm. I went to see him that morning. It was like I had never left. He was still waving his arms, gesturing angrily to an empty corner of the room to “leave me be, devil. Leave me be. You have no power here.”

But then he did something else. After waving his arms for a few more seconds, he brought them up to his temples, and started to massage them. “Migraines again, honey?” His wife asked. “They’re back,” he said. “They’re back, the pain, the great pain. Pain in my skull. My head. My forehead. ”

My mentor, Dr. Niraj Mehta, has a great saying about what to do when things aren’t making sense: ‘You either have the wrong patient, the wrong diagnosis, or the wrong treatment.’ Never mind the wrong diagnosis, I didn’t even have a diagnosis. I needed more of the history.

I spoke to the patient’s wife again. I wanted to know more about the chronic migraines. I asked her about how they had been treated. “Oh, it’s been awful. Ever since that car accident he gets them all the time. He’s seen the neurologists constantly, almost every month. They’re always changing the meds but nothing seems to work.” “What did they try most recently?” “Well, we just started scheduled ibuprofen and phenergan. They also just took him off valproic acid, which he’d been on for a few years now.”

Boom. The neurology notes! I’d read over them, but hadn’t paid close enough attention to the med changes. Valproic acid is an anti-epileptic drug, but works remarkably well as a mood stabilizer. It can even be used to treat depression associated with bipolar disorder. Now we’re getting somewhere!

I had a theory now. What if the valproic acid had been secretly keeping his hallucinations at bay since the car crash! Furthermore, what if he didn’t just have depression, but a thought disorder that also featured depression! I immediately started the patient on an antipsychotic medication called olanzapine. Antipsychotic drugs slow the surge of dopamine in the brain responsible for the symptoms of psychosis: thoughts, voices, visions, hallucinations. I also restarted his valproic acid. And then I waited.

The next day, I lingered by the door before walking in. Please work. I slowly opened the door, and for the first time since he’d been in the hospital, I heard beautiful silence. My patient was sitting bolt upright in bed, legs folded underneath him. His eyes were closed. He appeared to be meditating. His eyes fluttered open as I approached the bed.

“Good morning, doc.” His words were even and steady. They radiated calm. The Dalai Lama himself couldn’t have projected a more serene aura.

“How do you feel?”

“Doc, I feel better. The army… they aren’t coming after me as much. And there are less of them. The devil’s presence is fading. I can feel it.” His wife was beaming from the corner. “He slept perfectly through the night, nine straight hours!”

“Doc, when will it go away? When will I be myself again, back to normal?”

“I’m not sure,” I said. “Probably months. But the fact you responded so well to the medication is a great sign. This isn’t the sort of illness that corrects in a day. You’ll have to see a psychiatrist to manage your medications and to start therapy. They’re the real experts with this sort of thing. But you’re doing much better. I have a good feeling about this.”

“Sounds good, doc. Thank you.” He reached out again and held my hand. But this time, he wasn’t holding on for dear life. His grasp was firm and strong. He released my hand, and closed his eyes again, his expression determined but at ease.

Perhaps he was readying himself for the next encounter with the demonic army. Perhaps he was enjoying his newly gained mental solitude. Maybe he was just tired. Whatever the reason, he had more than earned this moment of tranquility. He’d been to hell and back over the past few days, pushed to the brink of sanity by demons of his own creation. He confronted chaos and fear head on, uncertain if he was losing his mind. He faced the ultimate test.

It didn’t take a doctor to realize that he had won.

Internal Medicine Resident Emotionally Wrecked After Consult Service Signs Off

HOUSTON, TX – In a devastating and unforeseen turn of events, neurosurgery signed off of internal medicine resident Dave McMillian’s patient, a 60 year old asymptomatic man with a 1 mm subdural hematoma, after following him for a week but recommending against any surgical intervention. McMillian was instantly reduced to tears upon hearing the news.

I found McMillian in his team room, sullen and beaten, and asked him to recount the events of the day. Staring blankly out of his team room window, Dr. McMillian bore the expression of a man who had become too trusting, and had let his guard down. His lower lip began to slightly tremble as he recalled the experience: “I just…I don’t know. I really thought we had something.” He continued: “You think you know a consult team…” before trailing off, a bitter half-smile curling from his jaw. A tinny rendition of John Meyer’s ‘Stop this Train’ could be heard through his computer’s small speakers.

I followed McMillian around that day. Confused and betrayed, he sought the advice of his attending, Dr. Rachel Johnson. “What does ‘follow from a distance’ even mean?” the crushed resident asked. “Follow? Do you think that means he still wants to talk to me?” “It’s over, Dave,” Dr. Johnson said, extending a comforting arm around Dr. McMillian’s shoulder. “It’s done. Trust me, I’ve been there. Give it a week or two, and maybe you can consult neurology for some residual weakness.”

I caught up with neurosurgery resident Ben Strictland in an attempt to understand the full picture. “It had to end,” said Ben. “It wasn’t going anywhere.” He fidgeted his hands uncomfortably. “We get ten, fifteen consults a day. I can’t just let every bright-eyed consulting physician sweep me off my feet. I have to be strong. Caution, temperance, and patience – those are my standards of care.” He took a deep breath, and his brow furrowed. “The brain…is the heart… of the head.” A single tear welled in the corner of his eye, tracing lines on his face that hadn’t been there only years before, then falling to the ground. “I have to be strong,” he said, this time with a slight waver in his voice. He turned away from me. Then, softer, and mostly to himself: “But you always wonder what could have been.”

 

Anatomy of a Wards Team

The medicine wards team is the bread and butter of the teaching hospital. To understand the type of care you’re getting at a hospital, it’s important to know the roles of the various members whether you’re a patient or practitioner.

 

Medical Student

  • Number per team: ~2
  • Experience: 2-4 years of medical school, plus various incredibly fake Standardized Patient* experiences.
  • Specialized role: dodging as much work as possible so that they can study for their shelf exams and actually learn something.
  • Underrated abilities: taking incredible social histories, copy-pasting resident assessment and plans, asking how the page operating system works, asking attendings questions (to ‘show their interest’) that prolong rounds by ~20 minutes per question.
  • Dies inside when: asked to obtain outside hospital records.
  • Common line: agreeing with anyone on the team about anything.

*an actor is paid to memorize a spreadsheet of symptoms and repeat them when prompted. It’s not very realistic. I wish the simulated schistosomiasis was more Shakespearean. “Ahhh! Hark! Doctor! Woooee is me! Ere I sat, with naught but a care in the world, when perforce did a foul ache spring forth from my innards and rest in my side. Methinks mine humours have been wrent asunder!”

Intern

  • Number per team: 1-2
  • Experience: 1-12 months of actual responsibility.
  • Specialized Role: discharging patients as soon as humanly possible.
  • Underrated abilities: constipation management, Tylenol dosing, instinctively resisting nursing staff requests to give patients “something to sleep,” ability to cry very discretely when looking at social media and seeing people actually enjoying their lives.
  • Dies inside when: a friend utters the phrase “what are you doing tomorrow?”
  • Common line: introducing themselves to other residents as ‘doctor’ so-and-so, before realizing how douchy that sounds.

 

Resident

  • Number per team: 1
  • Experience: intern year, plus between 1-6 years of additional training.
  • Specialized Role: actually knowing anything about how to help the patients.
  • Underrated abilities: showing up to the hospital the latest and leaving the earliest, conjuring a morning report out of a straightforward admission, worrying at all times that your interns are killing your patients, retaining sanity during 28 hour calls.
  • Dies inside when: discharges get delayed.
  • Common Line: [to intern, morning of surgery, anesthesia calls and asks for the resident] “YOU MADE HIM NPO, RIGHT???”

 

Fellow

  • Number per team: 0-1
  • Experience: Brittany Spears said it best: I’m not a girl resident….. not yet a(n) woman attending / All I need is time / A moment that is mine / While I’m in between.
  • Specialized Role: making you feel guilty for consulting their service.
  • Underrated abilities: competently managing patients within their specialty, forgetting all medical knowledge not related to their field, being grossly underpaid.
  • Dies inside when: consulted at 4:58 PM.
  • Common Line: [to resident] Tell me about the one you just saw. In 4 seconds.

 

Attending

  • Number per team: 1
  • Experience: years and years. Team leader. Most senior member.
  • Specialized Role: knowing how not to get sued.
  • Underrated abilities: adjusting the entire team’s rounding schedule based on little Billy’s soccer practice, warping space-time to somehow know what to do with a patient before they are presented, boosting team morale with food (re: buying loyalty), elegantly dissing the other team’s management decisions.
  • Dies inside when: they hear this before the one liner: “Ugh, this guy. Super complicated, he basically has everything. 6 admissions in the past 9 months….”
  • Common Line: “Strong work, team.”

On Truth, and Trust

I have an idealized version of myself. This version of me wakes up early and packs greek yogurt and (homemade) granola into mason jars. I pack gym clothes into my bag. I make coffee with time to spare. I stride out of my apartment at exactly the time that will allow me to be a few minutes early for work.

Then there’s the actual version. Some mornings I would barely pass as a functional traffic cone. Like Neo in the Matrix with, the way you perceive yourself can often be rosier than the truth. In the matrix, Neo’s hair is cut. His clothes fit a bit better.  He’s also not being hunted by sentient robot monsters. Perhaps it’s easier on the ego, or perhaps humans are just natural optimists, but it usually helps us to picture things in the best possible light.

Everybody lies. I lie. I’ve lied to doctors flat out. They say that physicians make the worst patients. It’s all true. The ones who know the repercussions of not following medical advice are often the most loathe to adhere to it. 7 day course of antibiotics for my bronchitis? That’s cute. How about 1?

The reason I bring all of this up is that medicine presents you with some very interesting ethical situations, specifically regarding lying and truth telling. In certain instances, you actually get to hold a pure lie detector test in your hand. I recently had one of these experiences with a patient who came to be one of my absolute favorites. I’ll call him Mr. Johnson.

Now, as most people in the medical field can attest, patient histories must be taken with a grain of salt. No matter what the guy slurring his speech, stumbling around your ER with breath that smells like the basement of a prohibition-era speakeasy tells you, it’s a safe bet that he’s been drinking. Taking a history is the start of a conversation. It’s one data point among many.

I was sitting down to take Mr. Johnson’s history. He had just had a heart attack, and I was trying to figure out why. I didn’t have to look very far – he had a history of severe coronary artery disease, he’d received coronary artery stents in the past for prior heart attacks, and had had multiple risk factors – older male, diabetic, history of cigarette smoking. But something else caught my eye looking over his chart: “history of extensive drug use.”

When patients are admitted to the hospital, they are triaged at several levels. The first stage is a triage nurse outside the ER, and the next is an ER physician. Much of the diagnostic workup is ordered in the ER, including quick resulting tests like EKGs and cardiac enzymes. Others take a bit longer to return, like urine drug screens.

When I went to speak to Mr. Johnson, I had the results of his urine drug screen back. Positive for cocaine.

I asked Mr. Johnson what he’d been doing when his chest pain came on. Nothing, he said. Had he been exercising? Nope. What had he been up to right before it came on? Just sitting at home, he said. I continued with the usual questions – where was the pain? Did it radiate? What did it feel like? Had he felt it before? Does he usually get chest pain when he exerts himself?

Now came the moment of truth. “Sir, have you used any drugs recently?”

Of course, I knew the answer already. But there was something more important at stake here. Did he trust me enough to share this info with me? Or had I come across as callow, uncaring; someone who would potentially judge him for this transgression. I had scanned his chart beforehand – no mention of drug use in the ER doc’s history. He hadn’t told anyone yet.

It’s easy to cling to our idealized selves. I was at my own checkup recently, and the doctor asked me how many times per week I exercise. “4-5 times per week.” Lie! He asked me how I’d been eating. “Mostly vegetables, and I’ve been really trying to avoid unnecessary carbs these past few months.” Lie lie lie! What did I have to gain by this? He knows my weight. He knows my cholesterol, my triglycerides. Is it out of self preservation? A refusal to look myself squarely in the mirror?

Mr. Johnson took a long pause before he answered.

I crave patient trust. As an internal medicine resident, I help my patients by altering long term disease progressions. Things like medication adherence, followup appointments, and lifestyle changes are paramount. Not the sexiest stuff, but immensely important. And it requires trust both ways. We trust patients to tell us their story accurately so we can make the right diagnosis and provide the right treatment. And they trust us to have their best interests at heart, to make sure what we tell them to do is worth it, and will actually help them. It’s pretty simple: If I have mutual trust with a patient, I can help them. If not, I probably can’t.

Before Mr. Johnson answered, I spoke up again. I told him, “Look, I’m not here to judge. I just want to know what happened so we can make the best medical decisions. Telling the truth is hard. But what you tell me doesn’t leave the room.”

“Doc, I’ve been clean for 6 years. I used to do everything. Heroin, cocaine, you name it. In and out of rehab. I’m 6 – er, was – 6 years clean, though. I swear. I absolutely swear. ”

“I believe you. What happened yesterday?”

“I messed up. I slipped. Coke. Not mine, though. A friend’s. I went to a party last night. My buddies are in town. From Cleveland…”

I had to know. “Are you…are you a Cavs fan?”

Mr. Johnson cracked a huge grin. He immediately hung his head, trying to look a bit more somber, but he noticed I was smiling too. His grin returned.

“Hail to the King,” he said.

“Amazing series,” I said.

And just like that, we had trust. The time for reminding him that drug use was bad for his heart would come, but not now. We spoke for almost an hour about the NBA finals, his childhood in Cleveland, his medical history. We spoke about his seven brothers and sisters, all of whom are now deceased. We connected. On my last day in the CCU, he asked for me to be his personal doctor.

He eventually had stents placed in his coronary arteries. I told him he’d have to take his blood thinners with Lebron-esque consistency. “I can do that,” he said.

I’m trying to learn from Mr. Johnson. It takes guts to tell someone you were wrong. You, alone, and not someone else. It’s hard to take responsibility for our shortcomings. But perhaps that’s what allows us to change.