Some sex irrelevant thoughts about patients

[Sharp-edge]

So these days I'm having my rotation at the Intensive Care Unit (ICU). Maybe it's me, but I tend to overthinkg at times. And now, I can't help but thinking the lives of the patients before ending up in ICU. Sometimes I'm happy because I get to see return back to the outside world and sometimes I'm sad because the patient dies. One of the saddest cases was that of a 40 yo woman with an untreatable disease (pulmonary fibrosis). I can stiill recall her unconscious breathing through the tube. Her hair had two colors because she was long unconscious and they were returning to their original color from the root. Maybe it's just me, but just this fact made me very sad. I was telling to myself that this woman was a part of the society, doing what we all do, visiting her hair dresser.. and now she's just dying for several weeks (now she's dead). That made me sad.

Sometimes you know, sometimes you don't. They say some doctors have god syndrom. Well I don't feel like a god, mostly I feel like someone who tries to tell the patient's future. Maybe I could discuss this with my friends, but I think here it's easiier, between strangers.

Other things that bug me are patients that have a very poor prognosis. I feel unable to help them. We have a patient with multiple metastases. We do what the guidelines state, we do the best we can. He's perfectly okay now, but I know that this will not last for long. He will get worse. And no matter the paliative care we will provide him, he will suffer. And that makes me sad.

But there's always the bright side. The patient who returns to his loved ones. And that makes me happy. 

[NWUSHorny]

I'm hoping I can give you a little optimism. 4 years ago I was in the ICU with stage 4 cancer,  almost paralyzed and a poor prognosis, I'm 3.5 years cancer free, physically active and very thankful that the people like you did not give up on me.  Sometimes it does work out.

[Sharp-edge]

On 3/23/2022 at 11:56 PM, NWUSHorny said:

I'm hoping I can give you a little optimism. 4 years ago I was in the ICU with stage 4 cancer,  almost paralyzed and a poor prognosis, I'm 3.5 years cancer free, physically active and very thankful that the people like you did not give up on me.  Sometimes it does work out.

I'm really glad it turned out well. I think we never give up, even when we know it's no use.

We have a guy these days that tried to commit suicide for the 4th time in his life. He won't make it (probably). That's sad. That guy was in pain (mentally) something bothered him very deeply and nobody managed to help him. I don't know who could have helped him, but nobody did. He was on antidepressants but I guess it didnt work.

And then, there is another guy that had a bike accident. He's in an induced comma, he's not in danger but if we try to wake him up he start to sweat endlessly (brain damage sign). I watch his mother during visits that she touches him and talk to him. You can feel her love. I mean it's obvious that she loves him, but feeling the love is intense. When I draw arterial blood (which is basically the only procedure I do to him as a training doctor) I just feel that one day as I bend his wrist he will grab my hand. But he doesn't.

I still haven't figured out the real purpose of a ICU. To extend the dying period of someone with no life expectancy? Or to be there for the very few that will survive? I am thinking of all the euthanasia thing. I would never be comfortable, if medical euthanasia was a thing in my country, to administer such a substance. On the other hand I think that "we torture" dying patients by keeping them alive. Maybe I'll be more happy or thinking less in my next rotation. O

[120DaysofSodom]

On 3/23/2022 at 4:46 PM, Sharp-edge said:

So these days I'm having my rotation at the Intensive Care Unit (ICU). Maybe it's me, but I tend to overthinkg at times. And now, I can't help but thinking the lives of the patients before ending up in ICU. Sometimes I'm happy because I get to see return back to the outside world and sometimes I'm sad because the patient dies. One of the saddest cases was that of a 40 yo woman with an untreatable disease (pulmonary fibrosis). I can stiill recall her unconscious breathing through the tube. Her hair had two colors because she was long unconscious and they were returning to their original color from the root. Maybe it's just me, but just this fact made me very sad. I was telling to myself that this woman was a part of the society, doing what we all do, visiting her hair dresser.. and now she's just dying for several weeks (now she's dead). That made me sad.

Sometimes you know, sometimes you don't. They say some doctors have god syndrom. Well I don't feel like a god, mostly I feel like someone who tries to tell the patient's future. Maybe I could discuss this with my friends, but I think here it's easiier, between strangers.

Other things that bug me are patients that have a very poor prognosis. I feel unable to help them. We have a patient with multiple metastases. We do what the guidelines state, we do the best we can. He's perfectly okay now, but I know that this will not last for long. He will get worse. And no matter the paliative care we will provide him, he will suffer. And that makes me sad.

But there's always the bright side. The patient who returns to his loved ones. And that makes me happy. 

Its always nice to see patients return to good health, but I dont think of dying as a sad thing really, more as just a part of life. I mean, everybody that ever lived has died, and only because of the CULTure that we live in, it has been beaten into us that to die is this terrible thing we must avoid. Its probably going to be nothing more than the billions of years before we happened to be born. We wont know we were ever alive, we wont miss anything, we wont be sad, or happy, or confused. Its part of what makes living every moment like its your last day on earth such a precious and valuable investment of ones time, and so when patients pass on the ICU I work on, I dont see it as a misfortune. The ones that leave behind children have already arranged to live indefinitely by passing on a torch. We do what we can to help each other in healthcare, but at the end of the day, we cannot postpone death indefinitely. I cant think for the life of me why anybody would even want to, or to live in hope that when we die, we go on to live in a fairy land for all of eternity. I take comfort in the presumption that when I die I will stay dead.

One of my friends that is a doctor in internal medicine and I often drink and discuss these things together, and he thinks im rather pessimistic, and sure, I can see why. We have been conditioned to think that way. He thinks like you do. Pondering why more couldnt be done, etc., etc. I think much of what we do in healthcare only adds to the suffering of some people, and I believe very deeply that euthanasia should be legalized, and more than palliative care, people should always be able to make the informed decision to end their life without having to suffer through that transitional period to our death, with no dignity, immobile, and defecating all over themselves. They should even be able to make those decisions when they suffer from mental illness and no longer want to receive treatment and just want to fade away. That is our right as human beings, to be the arbiters of our own body. Id rather die on my own terms, than wasting away.

[tallslenderguy]

A few thoughts.

i'm s Star Trek fan and it always makes me smile when "Bones" (the doctor in the original series) makes comments about medical care from our era, usually something like "It's barbaric."  We do the same, think of some of the medical procedures performed on the battlefield during war in the 19th century for example. my point is, healthcare is a finite process approaching an infinite universe. That's how i see the human body, as an infinite universe. We know a lot more now than we did in 1890, knowledge that makes us shake our head about our former ignorance. In  the year 2122, we'll likely look back on 2022 and shake our head about our former ignorance. 

i don't think anyone practicing healthcare consciously can have a "god complex."  "God," presumably, is all knowing. Don't have to be in health care long to realize how little we know in the grand scheme of things. Which is not to discount what we know, we do know a lot, but it's not much when put in the context of infinity.  

i often tell my patients: "we kill ants with elephant guns."  Sepsis protocol is a great example of that. A patient comes in with signs and symptoms of sepsis. We draw blood for cultures, then administer fluids and broad spectrum antibiotics. The antibiotics is a sort of scorched earth approach. We're likely only after one particular pathogen, but we don't know what it is, so we give broad spectrum (elephant gun) that'll kill everything. It usually takes a couple of days before cultures help us pull back and customize a more specific med. Even then, we don't always identify the specific pathogen, just general traits like: anaerobic gram negative rods.

Healthcare is replete with that kind of example. Cancer treatment involves a vast array of toxins we call medicine. 

i think we often make the mistake of equating extension of life with extending quality of life. The opposite is often the case. We often extend life at a great cost to quality of life. Heart failure and end stage renal disease are common examples of this, where we have the meds and technology to keep the body alive, but the life we preserve bears little resemblance to life prior to the disease.  

But in the bigger picture, it's part of progress. Look how many people suffered and died of AID's because of HIV, and now most can live out a relatively 'normal' life when infected.

Many people do get better and return to 'normal' life. But i suspect there will always be the in between group where we still do not know enough to get them back to where they were. 

my last rotation (i work on a critical care unit), i had a former nurse as a patient. He was in bad shape. 81 years old, COPD, acute kidney failure on chronic kidney disease, <20% EF on his echo cardiogram. His lungs sounded like a perpetual train wreck, and his coughing fits left me breathless just hearing them. He knew cognitively that he was in bad shape, but emotionally he was not ready to give up. He actually wanted to get his drivers license back (yikes!). So, i worked with him. got him up, took him for walks, gave him the little things that gave him hope, respite.

i look to love and help patients in the moment, improve their momentary condition. i touch and interact with  them a few days of their life, i try to not just look at their disease, but the whole person. That's hard to do, and i often fail. The system we work within pushes us to be task oriented, it's hard to be holistic.  We really never know which moment will be a persons last, can we make it better somehow? 

[hntnhole]

On 3/30/2022 at 3:45 PM, Sharp-edge said:

I still haven't figured out the real purpose of a ICU. To extend the dying period of someone with no life expectancy? Or to be there for the very few that will survive? I am thinking of all the euthanasia thing. I would never be comfortable, if medical euthanasia was a thing in my country, to administer such a substance. On the other hand I think that "we torture" dying patients by keeping them alive. Maybe I'll be more happy or thinking less in my next rotation.

Neither have I, unless it's solely to help those who have a decent chance of recovery.  When, however, someone has zero chance of recovery, and only a marginal chance to "exist" a little while longer (if it can even be called "existing"), I have nothing but complete disgust with those in the medical field who are so afraid of violating their Hippocratic Oath, or more coarsely, a lawsuit, that they refuse to allow someone to pass with some measure of dignity. If the patient had signed documents years before, clearly expressing their disinclination to be "forced" to endure, would you still be uncomfortable allowing your patient some measure of dignity?  I suspect not.  Our internist of decades, became a friend, actually made me pull the plug out of the wall - he was afraid to do it - we gave his kid a job for chrissake - and he was still unable to do the decent thing. All these years later I am still so disgusted about what happened, and how much worse it would have been had I not been sleeping in the room too (the moment came shortly after midnight).

I have close, intense and bitter experience with this, despite all the dnr's, documents drawn up by lawyers, and it didn't matter one bit.  Fortunately, I was present at the critical moment, and intimidated the medical personnel that came running when the horns started honking.  At least, he had me to run interference for him at the end.  For myself, I have had every possible legal document made, filed, cc'd to counsel, everything there is to do.  I just hope it works when it's my turn.  

[hntnhole]

8 hours ago, tallslenderguy said:

i think we often make the mistake of equating extension of life with extending quality of life

Not being personal, but yes - a lot of you do.  

 

8 hours ago, tallslenderguy said:

but the life we preserve bears little resemblance to life prior to the disease.  

Go ahead - you're allowed - you can say none, and I won't blame you. You're still one of the sweetest boys on BZ.  Iconoclasty is cool.

 

8 hours ago, tallslenderguy said:

i look to love and help patients in the moment, improve their momentary condition. i touch and interact with  them a few days of their life, i try to not just look at their disease, but the whole person. That's hard to do, and i often fail. The system we work within pushes us to be task oriented, it's hard to be holistic.  We really never know which moment will be a persons last, can we make it better somehow? 

But you try.  You do your best, in the worst circumstances.  You're caught up in it, and trying to do what little you can to focus on the patient's well-being in a holistic way.  Why don't you become Surgeon General of the US ???  Nah - that's a bad idea - why sacrifice someone actually caring for the whole patient to the will of Big Medicine.  They'd swallow you whole - bones and all.  

[yngguy712]

I’ve always thought doctors had to separate the person from the patient. Sort of like someone that repairs a high end watch can’t think that the watch is living with a soul.  They have to think mechanically. Except it’s not an exact science and every watch you get is different. They’re watches but some were made in China ya know. Some have had a hard life. Some were just given crap parts from the start. Others never did any preventative maintenance and now they’re barely keeping time.  Now fix me. But I can’t pay you. 
 

one profession I could never do is anything medical. Can’t separate the two.  And the whole not an exact science thing let’s just see what we get when we do this is insane.  
 

[cannero]

It's interesting speaking from the other side. I have been on cancer treatment from just before COVID started and was reviewed regularly before for a number of years. I often speak to my doctor and nurse about the fact I consider they are talking in terms of probabilities not predictions and my outcomes are far more positive than the diagnosis suggested a few years ago. As it is so positive and my doctor has seen this, I joke I'm one of his successes that help him through the days when those he treats are suffering far more than I. One day in the waiting room a family came out in utter tears having heard the worse, admittedly with what looked like a 95 year old. It was telling that my doctor and his nurse had to break for a few minutes elsewhere as their faces clearly showed they were equally as upset.

Personally I grappled with my mortality and am quite comfortable about a possible end, and part of that came from discussions about the pluses/negatives with the team about declining treatment and the pathway to death. While I discounted quite quickly the route of declining, it left me with the feeling my doctor was actually a good healer looking at me holistically, and since he's only relatively young, comes across with a sense of confidence and warmth.

[Sharp-edge]

10 hours ago, yngguy712 said:

I’ve always thought doctors had to separate the person from the patient. Sort of like someone that repairs a high end watch can’t think that the watch is living with a soul.  They have to think mechanically. Except it’s not an exact science and every watch you get is different. They’re watches but some were made in China ya know. Some have had a hard life. Some were just given crap parts from the start. Others never did any preventative maintenance and now they’re barely keeping time.  Now fix me. But I can’t pay you. 
 

one profession I could never do is anything medical. Can’t separate the two.  And the whole not an exact science thing let’s just see what we get when we do this is insane.  
 

For me, being a patient is a condition of a person in which he needs help. And having someone dying is a hopeless effort that you as a doctor can't give up on someone. Why can't we let someone die in dignity? Many reasons. The relatives of the patient may wish to support him with all means. The laws of the state/country. The beliefs about god that shape laws and personalities. And what i mean loss of dignity? Lying unresponsive to an ICU bed with a tube on your mouth that goes down your throat or through your throat. Another tube on your peehole and diapers. Your heart stops and you have it rebooted with CPR. That's all sad.

 

But sometimes, you get to get the patient back.

[hntnhole]

Thanks, guys, for the various viewpoints expressed.  It's a difficult subject, and at least we can offer each other differing viewpoints.  

[NWUSHorny]

I think it is important for the medical professionals to be fully honest about the potential outcomes and quality of life afterward with the patient and the family if the patient is not able to make the decision themselves. In my case they were fairly certain that they could get the cancer into a state of remission that would last for an extended period of time, there was a lot of uncertainty whether I would ever be fully mobile again, and I made the choice to move forward with the aggressive treatment. I am now told unless the cancer recurs in the next year and a half, that it probably never will, and I have regained 99% of my mobility.

I can also look at the situation of a relative of mine that recently passed at 91. He had a severe lung infection with a very poor prognosis in his late 20's and sought experimental treatments twice over a period of couple years. In his middle 70's he underwent cancer treatment and surgery that overwhelmed his weakened lungs (which he was warned about before starting treatment especially the surgery) and wound up on a ventilator for a couple of weeks. At 91 weakened by shingles and faced with the almost no prospect of resuming an active life he refused the ventilator (he was lucky enough to be conscious and mentally competent a until couple of hours before the end).  The most irrational choices he made were probably the ones he made in his 20's (and my grandparents may very well have been forced to make those decisions for him, I don't really know since it was before my time), but because of those decisions he enjoyed 60 plus years most of them with a high quality of life.

[hntnhole]

First, CONGRATS on regaining your health, and what sounds like a prognosis full of hope for a long, productive life.  It sounds like you were able to make the right decisions, given the correct information.  

Your relative also had a far longer life than he might have - your family must possess very strong genes - and he too lived a long life, with the ability to choose how and when he left this plane of existance.  How very, very fortunate for him, and the rest of his loved ones.  Most fortunate of all, it seems as though the medical people were caring and compassionate of their patients first and foremost, and worried about other, ancillary issues secondly.  I'm very glad you experienced these medical folks that put humanity first, and understood how crucial that is to the patient and the survivors.  

Thanks for the reply.  

[BootmanLA]

This thread should serve as a wake-up call/reminder for everyone: to the extent possible where you live, make sure you create legally binding documents that express your final wishes with respect to being kept alive by artificial means, with respect to resuscitation if your heart stops or you stop breathing, with respect to whether you want hospice care or heroic means to prolong your life, etc.

Of my grandparents, my dad's father struggled with emphysema for the last three years of his life and they were largely miserable years (this was in the 1970's). My dad's mother lived on mostly healthy for another 22 years and went "quickly" after she began to decline from heart failure. My mom's mom literally dropped dead of a heart attack - she was walking down the hallway of her house when she keeled over, dead - after essentially never being "sick" as an adult in anyone's memory. My mom's dad died a few months later of a heart attack, his second (and he'd also previously had a stroke). None of them had any written plans for how their care should be managed, and for the most part, it wasn't necessary, but we just don't know what might have happened if, say, one of them had become unresponsive and could not be brought to consciousness.

My parents, wisely, discussed this between themselves and with my sisters and I, made firm decisions about what they wanted, and had their attorney draft up the necessary papers to ensure (as much as was possible) that their wishes be honored. Neither wanted heroic measures, and neither wanted to be kept alive by machines if their quality of life was going to be severely impaired. My dad died of dementia 15 years later, without needing his paperwork (he died quietly at home), but my mother was able to use hers to ensure her final days were pain-free and peaceful as her organs were failing, rather than putting her on a ventilator to keep her lungs going and dialysis to keep her kidneys functional.

And bear in mind that in many places, an unmarried partner will have no legal right to direct your care if you can't direct it for yourself, unless you have expressly delegated that right in writing. If you're married, you're in much better shape, but still: getting this stuff worked out, unsexy as it is, can make your life a lot less stressful when it's needed.

[tallslenderguy]

On 4/1/2022 at 4:56 PM, hntnhole said:

But you try.  You do your best, in the worst circumstances.  You're caught up in it, and trying to do what little you can to focus on the patient's well-being in a holistic way.  Why don't you become Surgeon General of the US ???  Nah - that's a bad idea - why sacrifice someone actually caring for the whole patient to the will of Big Medicine.  They'd swallow you whole - bones and all.  

One of the most difficult and frustrating parts of working in healthcare is having to satisfy the demands of disconnected, and largely ignorant, bureaucrats/bureaucracy. They often seek to dictate how we provide care as though the healthcare provider is a remote control device.  Often, "those who cannot do, teach."   i'm part of a union, a whole different topic, and am always begging that we use our collective power to gain a seat on the board. Those who provide care should not have to settle for concessions, they should have policy decision making power. Or vice versa, those making policy should have to regularly do the work they are expecting others to do, they need to experience first hand what actual care giving involves. As it exists now, those who make policy are far removed from the process of care. They are buffered from reality by middle management. Middle management has to implement policy that they have no say in making.  It's a system that guarantees disconnect. 

i come from an executive management background. i have run businesses using a democratic consensus model that worked well. i switched lanes in 2010, went to school and got a BSN and became a bedside critical care nurse. i understand both sides of the coin experientially.  i have been asked by my peers to apply for management positions, and have declined, for the reason you state. The corporate model needs to be scrapped. It's a sort of Matrix that, as you note "swallows you whole."  One can make a difference, but it is individual and piecemeal. 

There is a lot of unrealistic expectation and notions about healthcare. The greatest, i think, is the notion that we are "healers."  Sort of, i guess. But really we, more more often than not, try to nudge or direct the body in a particular direction against a disease, and the body either heals itself or not. And that is a hugely complex process, much of which remains unknown and invisible.

 i've had 96 year old who was 'found down' three days after breaking a hip. They were altered mental status, septic, with renal failure. They left 4 days later, mostly restored to health.  So much of what we do is "wait and see." Some times kidney function comes back, some times it doesn't. Some times heart function comes back, some times it doesn't. And, we do not always know until we try. i think that is where there is a lot of failure in the system, the notion that we know what an outcome will be... or the expectation from the patient or family that we know that, when we often do not.  

People google and assume expertise based on a youtube vid or an article they read. They expect us to explain things that take years of education and experience to grasp. The bottom line is, trust is a huge component of healthcare. 

Edited April 3, 2022 by tallslenderguy