Dying the Natural Way

“What was the creatinine again?” the Critical care fellow asked, as I had rushed through the labs section of my presentation. In the time that I spent looking down at my notes to find the creatinine value, and reporting it, the fellow and I found ourselves alone at the patient’s door. We looked around to find that the remaining 6 members of our ICU team had ran over to the room next door. That room had become home to Mr. K for the past 2 weeks. His prognosis was dire. In fact, I remember my first introduction to Mr. K’s case being the following conversation:

“If he codes, we must keep it a very short code. We do not want him to suffer.”

There we were, at Mr. K’s door, looking up at a bradycardic rhythm. His heart was beating ever so slowly, at 30 beats per minute, irregularly, arrythmically. “Normally” we would call a code, fill his room up with nurses, physicians, staff, with a line of folks waiting to press on his chest and plea for his heart to beat rhythmically. But this was no normal occurrence. During Mr. K’s ICU admission, multiple attendings spoke with his wife about his wishes, as he was unable to make his own decisions. The complexity of a family member deciding if their loved one should undergo an attempted resuscitation, is in itself cause for another piece. For Mr. K, the conversations and understanding of his family’s position had evolved over the 2 weeks. At this point in time, while we stood in his room, the attending physician had been entrusted by Mr. K’s wife, to decide to not attempt to resuscitate him, if she deemed that the feeble body of Mr. K would not benefit from it.

“We are not running a code. Please give Fentanyl.” Our attending said, decisively, and to our relief. You see, seeing patients critically ill, with no realistic hope of return to a life with quality, we (as in, the collective healthcare profession) become partial to a certain acceptable way out of this world. Our human-ness comes out. We think, “Would I want that for me” and more appropriately yet “Should one want that for them”. The group of us standing in Mr. K’s room with him, watching him in his last minute of life, wanted this for him- the peaceful exit. We had seen the alternative on most days- the chaotic, loud, bloody, messy scene of a code. We cared about Mr. K, and were fortunate to have 2 weeks leading up to this moment to clarify what we should do in this moment. With most patients, we, and they, are not so fortunate. Most people do not like to think about their last moments.

Though we wanted Mr. K to have a peaceful exit, standing there, watching him die, was eerie. This was supposed to feel natural… yet it felt wrong. It seemed that the natural way to die, the default if you will, has been replaced in our minds as what happens most frequently in hospitals and on the media. The loud beep and the flat line, with the rush of white coats and scrubs who attempt, and many times, fail to bring the body back from the dead. That has become our default. My fellow medical student later reflected on this shared moment of Mr. K’s death that a reason she chose anesthesiology as her field is because while a patient is in the operating room, they are always “full code” meaning they will undergo attempted resuscitation. Standing by, not actively doing anything, while a person dies, was too difficult for my friend. Of course, I do not blame her.

Through it all, I gained the utmost respect for the ICU attendings who had the foresight to speak with Mr. K’s family, patiently, calmly, and slowly break down the misconception barriers of the role that attempted resuscitation did or did not have for Mr. K. I hope to emulate them, not allowing my career-born bias creep into my discussions with patients and families, but also tirelessly and patiently providing them the facts needed to make the decision of how their loved one may leave.

–Hedieh Matinrad, MS4

Untold Meaning

I handed her the humungous gardening shears and watched as she snapped through each rib providing access to the silent heart of our cadaver. Abruptly, the fire alarm rang out cutting short the most physically taxing day of our yearlong anatomy lab course. Once we had evacuated, firemen streamed into the building and I wondered if my lab-mates were also thinking about the horrific scene these men would encounter as they checked each room for stragglers. Garden tools rested on the half open chests of 24 lifeless bodies, globules of fat previously stripped away dripped into buckets below each lab table, and black plastic bags covered the faces of the anonymous men and women who had donated their bodies to medical education.

In elementary school I was deeply afraid of all things related to death and dying. At night I pulled my sheets up tight around my neck for fear that if there were any wrinkles left in it, it would look like a shroud and I would die in the night. I hated my bureau because it was big and rectangular and therefore looked exactly like a coffin. At Sunday school I could not drink from the water fountain because the water had certainly passed all the corpses in the graveyard on its way into the church. So, suddenly encountering dozens of pale, stiffened bodies, I thought to myself, “um, remind me again, why did I decide to go to medical school?”

As the fire trucks pulled away and we readjusted to the pervasive smell of formaldehyde, I thought about how quickly I had accustomed myself to slicing and combing through the unfamiliar territory of the human body. I was so fascinated by each new discovery that I forgot to worry about the proximity of death. Sometimes by the time I had changed into my scrubs and arrived at the dissection table my lab partners had already started and were ready to drill me on the day’s new terminology. “What’s this?” Mara asked, using her forceps to gently lift a white string running from deep within the neck down to the diaphragm. “The phrenic nerve?” I offered hopefully.

Relentless quizzing was a necessary evil because we had four exams to pass in order to move on to second year. The instructors tagged various body parts with numbers and we went from body to body writing the names of the tagged elements on our numbered exam sheets. It was highly unsettling to visit other lab tables. Each cadaver smelled foreign, this man’s cancerous liver made me wary, and his neighbor’s larger than life heart was unnerving. Shouldn’t someone formally introduce me to these people whose insides have been laid out before me? Without realizing it, I had developed a comfortable relationship with my own donor. I developed a relationship with a deceased woman who I knew nothing about beyond the elegance of her organs, the illnesses she endured during life, and the cause of her death.

My donor had passed by way of suicide. Throughout the year I tried not to make assumptions about the circumstances of her life and death but occasionally, as I walked out of the lab, my mind ran wild with questions. What had driven her to take her life after eight decades? Had she been lonely? In pain? Afraid? Or was it simply time to make that jump to the other side? We learned through the findings of our dissection that she had eaten within four hours of her death. What had she consumed? Did she make delicious molasses sugar cookies like my grandmother’s? We also discovered that she had fallen hard on her side upon passing and had lain for several hours before being found. Who had found her? Were they terrified beyond imagination at the sight or had they known this was coming? Did they grieve her still?

At the end of the year my class put together a memorial service for over 200 relatives of the donors. It was here, not leaning over a body with a scalpel, that I came face-to-face with the scariest aspect of death: the enduring empty space created when you die and the immense grief of those who remain behind. During the ceremony I stood in back with a woman whose mother was a donor. “I thought I had moved on, but clearly not,” she proclaimed, growing more distressed with each poem or piece of music my classmates had prepared to express appreciation to these loved ones. I listened and spoke what I hoped were consoling words. She told me I would make a great doctor and I remembered that I am in medical school to make the living more comfortable if only in small and temporary ways.

Afterward I spoke with two sisters who flew in from out of state just for the service. Their brother died while visiting San Diego and the family had been at a loss for what to do. For years, he had planned to donate his body to medicine but arrangements were only made to collect his body if he passed away in his hometown. They were grateful to the school for reacting compassionately and efficiently enough to grant him the honor of contributing to our education and the greater good of the world. “The donors are your first patients,” our anatomy instructors emphasized over and over again, “learn as much as possible from them while you have the chance.” Only then did I really grasp that our donors were patients who we could no longer save from death but to whose lives we had added untold meaning.

–Alicia DiGiammarino, medical student at the UCSD School of Medicine

Note: post originally appeared on Medium.com – https://medium.com/@aliciadigiammarino/untold-meaning-cf5eebfdbc73#.ahepvxhrt

“What could we have done differently?” | Thoughts on Institutional Forgetfulness

It is a question we often ask ourselves: “What could we have done differently?” Whether it’s when we’ve made a mistake, when an attending gives negative feedback, or when something unexpected happens, it helps us learn from our past. I find this to be an important question, and one that often guides me in medicine. Mistakes happen, and the process of a good medical education is full of trial and error. But how do we apply this learning to something bigger than a single person, like an institution or a school?

I visited a friend, also a medical student, in New York this past month. The day of my arrival, she informed me of some grave news: “A classmate of mine committed suicide this morning.” My heart ached for her school. I asked her if she wanted time and space to herself. She figured company would be good. Our lives paralleled one another– a year prior my school experienced a similar loss, and I tried to relate. But in those instances, it’s impossible to know exactly what a person is feeling.

As an outsider, I watched the tragedy of that morning unfold. My friend told me how their deans sent an email out to the school telling them someone had died but named no one. This caused a strange turmoil in her class given it could have been any member of their class that they lost. It was in whispers that many of her classmates found out who had passed and what had happened. The nameless email was just one of many things students felt the school had done wrong. Just hours later, school administrators held a student meeting. With just hours to process the day’s events people were already arguing, speculating the cause of this completed suicide, putting blame on the school and administration for unnecessary pressure the student likely faced. This meeting occurred while emotions were high; people were asking, “What could we have done differently?”

This event forced me to reflect on how my school handled its similar situation. I recall administration sending an email out, naming the passed student. Our school’s administration similarly held a meeting where we expressed our grievances with school stress, and need for mental health support. We were offered counseling, and made aware of the mental health resources available to us. Similar to my friend’s experience, students here were angry, upset with how the pressures we face can lead to things like this. But then months passed, and like lots of things in school, the passion that fueled concern for mental health and what had happened faded behind us.

I, too, asked, “what could we have done differently.” Though much can be said about suicide, and in particular physician suicide (here, here, here, and here), I wonder more about how we can institute change, and keep it relevant even after many of us have moved on. We shape our own personal knowledge by trial and error. But it’s difficult for us as transient four-year-students, to maintain an institutional memory of what we can do better. Administrators may persist, but those of us at the heart of wanting to create change are only temporary pillars trying to hold up this falling ceiling. We brainstorm ways to promote suicide prevention. We say, “this is how things should be.” But then we graduate, we move on, and leave future students who have not learned from our shortcomings.

In medicine, they say every patient is a teacher. In medicine you quickly realize people will die, you can’t save everyone. As healers we allow those we can’t save to become teachers, so that in the future maybe we can do something differently, and in the end save someone else. And in these two instances of losing our med-school colleagues, they have taught me the importance of mental health, that we need to address unnecessary stress, and we need to uncover and resolve systemic problems. But by evidence of persistent issues with higher rates of health-professional suicide, I’m not sure if institutions are remembering what they could have done differently. We need to figure out a way to remember what we have learned and not let time wear down these lessons.  And unless we fix this problem of institutional forgetfulness, we will keep asking ourselves, “What could we have done differently?” Unfortunately, this is a question of which I still have not found the solution.

 

With a heavy heart,
Bradford Nguyen


For those who wonder what we can do, suggestions from Jamie Riches, DO (http://blogs.jwatch.org/general-medicine/index.php/2016/07/what-is-resilience/):

“What can we do?

  1. Eliminate the word “burnout” from the lexicon: Not only does burnout minimize the severity of depression, detachment and (at extremis) suicidal ideation among healthcare professionals (HCPs), it implies that those suffering post-trauma have some inherent flaw or weakness that impairs their ability to remain functional. This mindset removes the onus from the system.
  2. End the stigma: Remove the question, “Have you ever sought treatment for any mental illness” from the job applications. We should encourage residents, physicians at all levels, and other HCPs to actively seek out cognitive therapy as we do vaccines or PPDs.
  3. Decide what graduate education is: If residents are primarily learners, we must protect their time and use it solely for educational (both clinical and didactic) purposes and not to provide underpaid labor to perform all tasks for which the hospital is at a loss, no matter how menial. If residents are employees, we must provide adequate pay for educational level, protect sick leave, and outline contractual responsibilities before enrolling in the agreement.
  4. Stop penalizing unwellness: Physicians and HCPs are as human as our patients. We are not immune to everything. There will be times when we will be ill, physically and emotionally. We will need time and space to heal.
  5. Structure the system in a way that minimizes fear of retaliation: If the person creating or enforcing destructive policies is the same person who needs to write the words “excellent candidate” on the letter of recommendation that carries the weight of your future career opportunities, your best and worst interests are one and the same.
  6. Embrace our own fallibility: Learn to be comfortable with imperfection. Let us have an equal respect for our accomplishments and failures. Employ mentors who set this example.
  7. Accept that medicine is not martyrdom: The work does not stop. Let it not deplete us. Let us take care of each other and ourselves and not give away everything that we need.”

Labor and Delivery, Harvey Dent (AKA “Two Face”), and President Obama’s Speech

My last day of my third year clerkship rotations perfectly encapsulated much of what I love about academic clinical medicine and much about it that breaks my heart.

This final day began on the labor and delivery (L&D) service at the UCSD county hospital in Hillcrest. As the morning progressed, I found myself unconsciously checking off the boxes in my mind as tasks were completed. “Shut off my alarm at 3:30 am for the last time (for a few months at least), check.  Awaken women who have recently delivered a baby at insanely early hours to ask how they are doing and do a targeted physical exam, check. Frantically write my notes to get ready for rounds, check. Try not to look like an idiot on rounds, mostly-check.”

After the morning routine that becomes all-too familiar during third year, we ran the board on the L&D deck. The L&D unit was offering all the chaotic glory it had to offer that day: high risk-pregnancies, scheduled and unscheduled c-sections, and low-risk vaginal births attended by the certified nurse midwives were all in the cue. As I wondered where to get involved, my resident suggested I assist with the vaginal delivery of a woman, Mrs. Tran, who had just been examined and who felt ready to start pushing.

We walked over together, and as we entered the room, I felt an ambiance I had not yet experienced during my time on the L&D service. It was one of complete tranquility. Mellow, soft, flute and chime music played in the background. The shades were low, and the lights were dimmed. Mrs. Tran lay on the bed relaxing, with a peaceful disposition, as if she were awaiting her turn on the massage table. Was this a spa or a hospital room? Her husband stood by her side, holding her hand, and frequently spoke kind and encouraging words to her. The nurse was on the other side of the bed, monitoring the status of her IV lines and epidural.

My resident and I left the morning’s chaos at the door, and dropped to the pace, feeling, and volume of Mrs. Tran and her delivery. We introduced ourselves, asked if it was okay if I assisted with the delivery, and questioned if she was feeling ready to push. After a look to her husband, a smile, and two answers in the affirmative, we prepared to deliver the baby and she started pushing. She pushed almost effortlessly for ten minutes, after which a beautiful baby girl transitioned from life in the womb to life outside. The joy mom and dad felt was palpable. As my resident and I cleaned up, I thanked God in my heart for the opportunity to experience in my small way of this important family bonding moment–what I had come to call “a family glue moment” by the end of my rotation.

Still basking in the idyllic feeling from Mrs. Tran’s delivery room, I was snapped back to reality as I reached the L&D deck. A woman I’ll call Linda had brought herself to the L&D triage unit, which is basically the Emergency Room for pregnant women, because she felt like her baby was moving less than it had been previously. My resident connected me to the Certified Nurse Midwife (CNM) who was managing the triage assessment, and she said she would love to have me help with the patient.

I began reviewing Linda’s chart, and soon my heart broke. She had been seen several times in prenatal care, so we already had a fair amount of good information to help us assess her and the baby. But it was also clear that she had numerous personal and health risks that we needed to check out. Now in her mid-30’s, she had a complicated pregnancy history, though we didn’t have much detail; she was in an narcotic addiction recovery program, and was currently taking the medication that helps with that called Methadone; and while stable now, she had recently had problems with being homeless. Perhaps the point where these problems started was in her childhood, when she had been the victim of sexual abuse and had turned to and was victimized by prostitution and drug abuse for many years thereafter.

The chart made it clear that Linda was making great efforts to stay off drugs and out of legal trouble so she would be permitted to keep her baby. And on that day, it was the job of me, the CNM, and the whole hospital system to make sure that she and her baby were healthy and safe.

The CNM introduced me to Linda and asked if we could get a better idea of her history and how she and her baby are doing. Linda agreed, and she shared that she had actually had two deliveries in the past. One was in Florida to twin girls that were born prematurely, helicoptered to another hospital where they could get life-saving care. After they were placed on the helicopter flight, she signed the adoption paperwork and never saw them again, because of her legal and personal state. Her other birth was to a boy in New Jersey, with whom she was able to spend a couple of days before putting him up for adoption as well. Even though Linda shared with me her story with the callous of a woman who had experienced life-shattering traumas, it was evident she still harbored sadness. It was also clear the great efforts Linda was taking to try and be a good mom and to be able to keep her this baby.

After further discussion, an ultrasound, and other tests, we were able to reassure Linda that her baby was moving well, that she and her baby appeared healthy, and that she could return home. Linda thanked us for the care and attention we gave her and her baby, and began preparing to go on her way.

After my encounter with Linda, two verses from a hymn in my Church’s song book came to mind:

Who am I to judge another
When I walk imperfectly?
In the quiet heart is hidden
Sorrow that the eye can’t see.
Who am I to judge another?
Lord, I would follow thee.

I would be my brother’s keeper;
I would learn the healer’s art.
To the wounded and the weary
I would show a gentle heart.
I would be my brother’s keeper–
Lord, I would follow thee.

(“Lord, I Would Follow Thee”, LDS Hymnal #220)

Leaving the hospital later that afternoon, I felt grateful to have been able to participate in my small way in the care of my sisters, Mrs. Tran and Linda. While reflecting on how one brief day had provided opportunities to help women who were on opposite ends of the socioeconomic and social determinants of health ladders, the image of Harvey Dent and “Two Face” came into mind.

Image result for harvey dent good guy

 

 

 

 

 

On one hand, I appreciated the role of academic medicine, and how as an institution, in its ideal though imperfect form, it strives to care for all people regardless of background; on the other hand, I was troubled at how familiar Linda’s story had become to me by the end of my third year clerkship rotations–that of traumatic childhoods, struggling families that too frequently break, the long-term health effects of terrible, selfish acts committed by others, the harmful minute-by-minute influences of one’s community and environment, and a society and healthcare system that rather than being one step ahead is more often than not is two steps behind.

We all know medicine is imperfect and needs major overhauls. And it’s not just medicine–the recent killings by police, the recent killings of police, the increased frequency of mass shootings (to name a few)…it makes one wonder, where is the hope? Rather than try to unpack each of these issues in this post, and without touching on all of the approaches that need to be taken to fix these issues, let me focus on one thing that has been on my mind.

The hope is in each one of us to grow, change, and influence the world around us for good. Let me apply the case of Harvey Dent to our current discussion: is Harvey Dent all good, or is “Two-Face” all bad? One reason his character strikes so close to home is that we subconsciously realize that we are all like him: looking good and trying to do good in our best moments, while appearing monstrous and almost unrecognizable in our worst ones. This is why we extend compassion and understanding to Dent so easily, for we all recognize the wort of us in ourselves as well. Hence the relief we feel at his death, because we are glad the darkest side of him is no longer around to wreak havoc. Perhaps this is also why we accept Dent’s portrayed martyrdom as a hero in exchange for Batman’s antagonizing sacrifice, because we too want to be remembered for our good deeds rather than our destructive ones.

The analogy can be extended to our spheres of influence in clinical medicine, and our day-to-day contributions to society. In similarity to Harvey Dent, each of us who fulfill a role in clinical medicine–big or small–is responsible for tremendous acts of individual care: lives saved, diseases prevented or cured, hearts and minds strengthened, along with many more examples. On a personal note, my orthopedic surgeon gave me my ankle back after I had a traumatic fall and fracture five years ago. Each time I step onto a soccer field or run around with my kids, I wonder at how my mobility could be very different without my surgeon’s knowledge of mechanics, bones, and pins.

But let’s not allow the “Two-Face” within each of us to hide behind the martyred Harvey Dent. How do we feel when caring for a Trump supporter? When the door to the resident workroom is closed, what are we saying about our patients, and perhaps more importantly, in what spirit are we saying it? Are we pushing ourselves to engage in those kinds of conversations that promotes understanding with others, including our patients, who look, think, or act differently than us? I went back to President Obama’s speech he gave at the Dallas Police Officers’ Memorial Service to grab the bit where he says we need to have difficult conversations about race and other issues with those outside of our circles. But reading through it, his moving remarks are connected to the Harvey Dent analogy, the socioeconomic determinants of health issues brought up by Mrs. Tran and Linda’s stories, and our individual responsibility to change ourselves and strive to make change around us. It’s long, I apologize, and I know it was considered by some to be a controversial speech, but it’s too important to not highlight. Recall that this speech was given at a memorial service for slain police officers in Texas. I’ll let him do the talking, and close using his pleadings (bold added for emphasis):

“We can’t simply dismiss [the black community’s calling attention to persistent inequities in how they are treated compared to their white counterparts] as a symptom of political correctness or reverse racism. To have your experience denied like that, dismissed by those in authority, dismissed perhaps even by your white friends and coworkers and fellow church members, again and again and again, it hurts. Surely we can see that, all of us.

“We also know what Chief Brown has said is true, that so much of the tensions between police departments and minority communities that they serve is because we ask the police to do too much and we ask too little of ourselves.

“As a society, we choose to under-invest in decent schools. We allow poverty to fester so that entire neighborhoods offer no prospect for gainful employment. We refuse to fund drug treatment and mental health programs.

(APPLAUSE)

“We flood communities with so many guns that it is easier for a teenager to buy a Glock than get his hands on a computer or even a book.

(APPLAUSE)

“And then we tell the police, “You’re a social worker; you’re the parent; you’re the teacher; you’re the drug counselor.” We tell them to keep those neighborhoods in check at all costs and do so without causing any political blowback or inconvenience; don’t make a mistake that might disturb our own peace of mind. And then we feign surprise when periodically the tensions boil over.

“We know those things to be true. They’ve been true for a long time. We know it. Police, you know it. Protesters, you know it. You know how dangerous some of the communities where these police officers serve are. And you pretend as if there’s no context. These things we know to be true. And if we cannot even talk about these things, if we cannot talk honestly and openly, not just in the comfort of our own circles, but with those who look different than us or bring a different perspective, then we will never break this dangerous cycle.

“In the end, it’s not about finding policies that work. It’s about forging consensus and fighting cynicism and finding the will to make change.

“Can we do this? Can we find the character, as Americans, to open our hearts to each other? Can we see in each other a common humanity and a shared dignity, and recognize how our different experiences have shaped us? And it doesn’t make anybody perfectly good or perfectly bad, it just makes us human.

“I don’t know. I confess that sometimes I, too, experience doubt. I’ve been to too many of these things. I’ve seen too many families go through this.

“But then I am reminded of what the Lord tells Ezekiel. “I will give you a new heart,” the Lord says, “and put a new spirit in you. I will remove from you your heart of stone, and give you a heart of flesh.”

That’s what we must pray for, each of us. A new heart. Not a heart of stone, but a heart open to the fears and hopes and challenges of our fellow citizens.” (President Barack Obama, June 12, 2016)

With love,

Spencer

 

** all images taken from either Google Images or Bing

ID: 17 year old Hispanic female who attempted suicide with Tylenol, now medically cleared and admitted for psychiatric evaluation

Dear John,

I have wanted to write a letter to you, an 18 year old man I have never really met, since I had the privilege of meeting Diana, your ex-girlfriend, during her admission to the Child and Adolescent Psychiatric Services program.

My intern Will and I found Diana settling into her newly assigned room. She was wearing a faded navy sweater two sizes too large for her frame. We introduced ourselves and asked if she would accompany us into a nearby room so that we could talk comfortably. As we walked in the hallway, she tied her freshly washed hair into a bun and pulled up her enormous hood. No longer could I see her deep brown eyes that were hazy with unfallen tears.

In the interview room we oriented ourselves in a small triangle: Diana and me on a couch together, Will in a chair across from us. His voice was gentle and questioning was focused, “Diana, do you know why you are here?” She withdrew her hands into the giant cuffs of her sleeves and brought her knees to her chest, hugging herself. No one said a word for 10.. 15.. 20 seconds. She brought her right hand to her face, covering her mouth with a giant sleeve. 30.. 45… She sat still. A minute passed — that trick we were taught, to be comfortable with silence, didn’t seem to be working. It was Will who eventually broke, “Diana?” Muffled and cracking but without hesitation, “I took the pills because I couldn’t take it anymore.” “What was it that you couldn’t take?” he followed up. Slowly but a little louder,

“He hit me again.”

I could see the navy blue sleeve that was covering her mouth grow darker with tears, mucus, and saliva.

This was my introduction to you, John. I know it is an unfair and biased way of meeting you, but this was it.

Will asked what happened. Diana answered in an even tone.

“I had just gone to lunch with a friend so I didn’t respond to his text right away… So when he dropped me off, ’cause he drives me home after school… He was upset ’cause it took a long time ‘til I texted him. Just before he pulled in front of my house, he hit me on the leg. Punched I guess. And when I got home I just went into a daze and went to the bathroom then my room. I texted him that it was over, I opened the bottle, and I swallowed however many pills there were. And that was it. My mom found me and I guess you guys know the rest.”

And she was right, we did know the rest of the medical course. The arrival at the emergency department by ambulance, the trends in her liver function enzymes and blood clotting factors, closely monitored to evaluate for signs of acute liver failure. But that’s all we knew. Her trauma, your abuse; we were ignorant, and she the only expert in her experiences. So Will pressed her for more information. He conducted the formal intake interview, running through the necessary check-off list of SIGECAPS, family situation, access to weapons, etc. She responded with yes, no, I don’t know, or other similarly short answers. He then asked, “Do you feel hopeless?”

Diana sat back in the couch and pulled her hood off her head. She dropped her knees and lowered her hand. It looked like she suddenly grew before my eyes, spine lengthening two or so inches — now maybe even fitting that gigantic sweater. She wasn’t hiding anymore. She was not shrinking herself now. Something in her was alerted in that question.

“I don’t actually want to die. I don’t know if I wanted to die then. No, I don’t think so… Nothing was even different about that day. But uh yeah, I have hope. The only reason I told anyone what happened in the first place is I realized that if I don’t, he’ll just do it to another girl.”

John, Diana’s reason for maintaining hope was the possibility of ending your cycle of gender-based violence. Here we were, trying to unpack our patient’s traumatic experiences of intimate partner violence, to which one in ten U.S. high school students are subjected [1]. And Diana’s source of hope was not for herself but for another girl; Diana was protecting a sisterhood whose members were unknown but connected to her.

Will wrapped up the interview efficiently, assessing quickly that her suicidality had a specific trigger; there are increased depressive symptoms and suicide attempts among women who experience intimate partner violence [2]. He thus became eager to schedule a family meeting in which strategies of preventing a future suicide attempt could be discussed. It felt somewhat rushed, but what in medicine these days isn’t? Will turned to me and asked, “Nicole, do you have any other questions?” Any other questions. As if I could think of just one i he forgot to dot or t he forgot to cross.

“I have a few. Diana, is it okay if I stay behind and chat with you for a bit while Will meets with our supervising doctor?” She said, “Sure” and I felt grateful she was willing to humor me.

I turned our conversation around and we talked for half an hour about where we were from, what we wanted to do when we grew up, what it is like to be older sisters. We laughed at the way we each liked each others’ hair but not our own, and how the things we cared about as freshmen in high school seem so silly now. And when it felt like we could no longer ignore it, I turned to her and said that she is a fierce young woman, that this abuse was not her fault, and that her internal strength is obvious to me, someone who had just met her.

She said, “I know it is not my fault,” as she lifted her sweatshirt and pushed up her basketball shorts to reveal thighs covered in various hues of pink, red, purple, and blue. I remembered that you hit her again, that this incident was only unique in what happened afterwards to bring her into the hospital, not in the physicality of it.

“I know it can’t be. But I am ashamed. I feel ashamed I let this happen to me and that now my mom knows and how much she has cried. I hate to see her cry and I just don’t want her to cry anymore.”

I can’t even begin to imagine the pain a mother must feel to know that her daughter has been hurt, despite all motherly attempts to shield her. But again, I was humbled by Diana’s foremost concern for someone else. Her shame was rooted in the pain she believed she was causing her mother. In reality, John, you were the one hurting Diana’s mother.

She had an uneventful, which is to say good, remainder of her hospital course. I would check in with Diana daily and watch her self-confidence grow. She looked forward to family meetings during which time she’d hold her mother’s hand as a Spanish translator updated her on the status of the police report, restraining order, and insurance coverage. With Latina women less likely to formally report intimate partner violence than white women [3] (though this could actually be mediated by women’s economics given minority women’s disproportionate poverty burden [4]), I felt all the more inspired by Diana’s decision to seek action. She was nervously excited about going back to school because she had missed so many classes, but was in communication with her teachers who seemed understanding. When it was time for discharge, we hugged and I said goodbye to one of my youngest teachers. I can’t believe how much Diana taught me about female resiliency.

And John, while I am very clearly an ally of Diana, I also consider myself your ally. This is why I have wanted to write you a letter for so long.

You grew up in a world that prioritizes mens’ desires over womens’ rights. Masculinity is revered and central to growing boys’ and mens’ identities. And this maleness is predicated upon obtaining all that is presumably yours, by any means possible. A woman’s disobedience is thus not only an affront to your control, which must then be reasserted when challenged, but also to the core of your identity. This is the gender power dynamic ingrained in our society. You internalized it. And then you externalized it. So now we have “met.”

John, I am angry because of your gender-based violence and society’s complicity and tacit approval. Despite this anger, like Diana I too have hope. I hope that you take responsibility and own the abuses you committed against Diana. I hope you are able to see that your expectations of a partner were gendered, and that you took inhumane steps to obtain that which you assumed was yours. And I also hope you see that you were wrong in part because society is wrong, and that you have the obligation and opportunity to change it. I hope you see this daunting task as a collective responsibility. Because in actuality it is our duty to upend and redefine masculinity, and I hope you join me.

In solidarity,

Nicole

[1] Gressard, Lindsay A., Monica H. Swahn, and Andra Teten Tharp. “A first look at gender inequality as a societal risk factor for dating violence.” American journal of preventive medicine 49.3 (2015): 448–457.
[2] Devries, Karen M., et al. “Intimate partner violence and incident depressive symptoms and suicide attempts: a systematic review of longitudinal studies.” PLoS Med 10.5 (2013): e1001439.
[3] Kaukinen, Catherine. “The help-seeking strategies of female violent-crime victims the direct and conditional effects of race and the victim-offender relationship.” Journal of interpersonal violence19.9 (2004): 967–990.
[4] Barrett, Betty Jo, and Melissa St Pierre. “Variations in women’s help seeking in response to intimate partner violence: Findings from a Canadian population-based study.” Violence against women17.1 (2011): 47–70.

Originally posted at femd.

This is wack

High Fructose Corn Syrup is straight up sugar crack

You and you and you all best believe that!

I saw you take that one liter soda off the rack

Put it right back

Because obesity will sneak up and attack

In the 1980s, crack plus black pushed an entire community back

That was wack

But in 2016, it’s the same story, Jack

Minority communities running rampant with the Big Mac

Or the box with jumping Jack

Or a King who makes it your way like he’s got ya back

But the BMI is so high you can’t even see your back

Or your arteries are clogged with that nasty plaque

You might as well get ready for a potentially fatal heart attack

I can’t even believe that

Then they put the blame on them because they can’t make it around the track

And not on the multiple resources that they lack

This is so wack

I’m not taking what I said back

CDC got all the statistics in a stack

Piled so high, they are falling off the rack

And every year, they will continue to increase until we act

This is wack

No, I’m not smoking crack

Or throwing that liquor back

The only thing coming out of my mouth is fact

In 1977, McGovern tried his best to get us off this track

But all the lobbying food industries (junk, diary, meat, salt and sugar)……..that entire rat pack

Came out the woodwork and they all clapped back

For them the profit is gold and your life don’t mean jack

My hand can’t get to their faces fast enough to smack

I’m so over the effectiveness we lack

In “trying” to bring the nation’s health back

With dietary guidelines that need a whole lotta feedback

With hospitals vending every type of snack

Children television advertising all kinds of junk and crap

Foods that glow in the dark and create dental plaque

and never ever ever ever grow mold like that

This game needs a new quarterback

A totally new plan of attack

because to be quite honest

At this point, this is just BEYOND wack

And I am not about to just sit back

And watch lives unnecessarily fall through the cracks

I don’t find it too hard to tell folk to tone down the fat back

And the oreo snack pack

But you got have the relationship and the tact

Or your patients will be out the door with their knapsack

And the American and global culture need a comeback

They need to have the desire to want to bring health back

We should be hunting down chronic disease like a wolfpack

I want folks to get their lives back

And if that means I might catch some flack

Come at me homie because research has got my back

Akesson et al 2012 in particular can tell you that

Most heart attacks disappear if the burger gets put back

Monetary and political interests need to fall the hell back

And the power of the people and their interests needs to come back

Mic drop

Now tell me can you handle that

 

Marsha-Gail Davis, MS4

 

 

I am too nice for general surgery

People often tell me I am too nice for general surgery. That I don’t fit the culture. But over the past few years, I have seen some of the greatest acts of compassion performed by my surgical colleagues and today, I’d like to ask you to challenge that stereotype. 

No one wants to have surgery. The day you are told you need a surgery, whether for gallstones, appendicitis or a newly discovered tumor, is often one of the scariest in a patient’s life. To allow another human to put you to sleep, paralyze you and cut into your body, entering portions of your self that you have never seen or felt with your own hands, and then sew you back together requires complete trust. So what kind of doctor would you like to see in that scenario? What qualities would you like this person to possess? 

I would hope for a physician who understands the fear that exists pre-operatively. My patient came to clinic one week prior to his surgery, a pancreaticoduodenectomy, or whipple, for pancreatic cancer. His initial imaging work up had shown a questionable liver lesion, so he had already had a diagnostic laparoscopy with a liver biopsy which luckily returned as benign. He went on to complete two weeks of neoadjuvant chemoradiation, which he tolerated remarkably well. So here he was to discuss his surgery. He had worked as an engineer his whole life, and wanted to discuss every detail. How long is the surgery? How will I feel when I wake up? Where will I recover? How long will I be in the hospital? When will I be able to eat? Will you update my family? How quickly will I be able to see them after I wake up? His questions shifted from surgical logistics to the wellbeing of his family. The surgeon I was working with remained until every question was answered. He drew pictures, he reassured the patient, he provided comfort to his wife and he got further and further behind in his clinic schedule. But in that moment, as that patient prepared for the scariest day of his life, he was 100% his. 

I hope that my surgeon is thorough. Our patient was asleep and prepped on the table for his whipple. My chief resident and I opened the belly and began to explore the abdomen for any metastatic disease. Now remember, this patient had already had negative liver biopsies one month ago. So our suspicion was low. But we felt something on the liver that wasn’t quite normal, so we sent a biopsy to pathology. We then proceeded with the first part of the operation, a cholecystectomy. Our attending scrubbed and we continued the case, mobilizing the duodenum and dissecting out the pancreas. 

The phone rang in the OR and it was pathology. “Calling regarding patient X, medical record number 159375. We have results from a liver biopsy. Biopsy shows metastatic adenocarcinoma.” The OR was silent. All hands stopped moving in the belly. “What? How is that possible? We have benign biopsies from a month ago”. The pathologist “we know, and we compared to those samples and this is definitely metastatic disease. Can you send more tissue?” “Yes definitely, we will send a second biopsy”. So we went back to the liver, to another place that didn’t feel quite right, and sent another sample. 

And then we waited. 

The phone rang. “Hello this is pathology, calling regarding patient X, medical record number 159375. We have results from the second liver biopsy. This also demonstrated metastatic adenocarcinoma.” 

So what does this mean? We are already in the abdomen, should we just do the surgery, we have already started? No. All we can do now is palliative procedures. The prognosis after a metastatic pancreatic cancer diagnosis is 3-6 months.  All we can hope to do is to make him more comfortable. So we performed a gastrojejunostomy, bc as the tumor grows it will obstruct his duodenum, making him unable to eat. Hopefully this will allow him to keep his digestive track open for longer. And we performed a celiac plexus block to help alleviate abdominal pain he will certainly develop soon.

I would like a physician who is honest, even when it is painful. After closing, our attending went down to speak with the family, his wife and daughter, and explain what we found and the prognosis. Our patient wheeled to recovery. After an hour, his family joined him in recovery, knowing his new diagnosis, while he lingered in the post op twilight. 

Later, we returned to the bedside to tell our patient that we could not complete the surgery. His wife held his hands and he looked to our attending for hopeful news. He explained that we took another liver biopsy when we got in and that it returned as metastatic cancer. I watched my patient’s eyes as it began to register. His shoulders tightened, he looked to his wife and back to our attending. Tears welled in his eyes. His wife squeezed his hands and cried and told him she loved him. He did not ask questions, he just was. My attending squeezed his arm and we left him with his family. 

We walked back to the floor in silence. Each of us lost in that family’s pain and their love.  

Unfortunately, this is not the first or the last of those conversations that my attending has experienced. He has dedicated his life to pancreatic cancer and caring for patients as they face a terrifying diagnosis. 

So I ask, is he too nice? Is the pediatric surgeon operating on your child, too nice?

These are the surgeons that I have worked with. And these are the physicians who have shaped me, inspired me and taught me that compassion exists in every specialty, even general surgery. I hope that none of you will fall into the trap of believing these stereotypes, and you will be too nice for all specialties. 

Taylor Coe
MS4