Family Meeting

With my medicine clerkship coming to an end, I realized that I had not yet taken part in a family meeting. Since I felt that this was an important process to experience, I asked if I could attend when my resident mentioned she had one scheduled one afternoon.

Having a family meeting in a hospital is usually not a good sign. It probably means that the patient is extremely ill, and isn’t well enough to make their own medical decisions, so their family members and doctors have to come together to negotiate a plan.

The meeting that afternoon was for a patient I had not been following. I quickly looked over her story - pancreatic cancer, kidney cancer, liver metastases, two giant abdominal wall hernias causing multiple intestinal obstructions. That last thing meant this 70-year-old patient has not eaten for 5 days now. So naturally, when I asked the palliative team in the meeting room if I could attend, they were very hesitant. “Only if it’s okay with the family, and if you quietly watch from the corner,” they concluded.

Lucky for me, the patient’s three children could care less if I was there or not, so I pulled a chair to the corner of the table, and commenced to be a fly on the wall.

The three children sat on one side of the table – the son was big and handicapped with a cane, one daughter had spikey short bleached hair with two full sleeves of tattoos (birds and dragons), the other daughter had a tight ponytail and pursed lips. The two palliative nurses and medical resident sat facing them on the other side of the table.

The meeting began with the facts. Your mother’s intestines are twisted around in such a way that nothing can get through; this means she cannot eat – it might burst if you put more pressure on it. If it untwists, we can feed her. If it doesn’t, we cannot.

The son held the conversation through all of this. He was calm, collected. What are the options? He asked reasonably.

We can’t do surgery – the cancer is too advanced, the surgeons signed off. There’s no treatment for her cancer. There is nothing we can do for her twisted intestines. We cannot give her food; we cannot give her water.

The daughter with the spikey bleached hair began to shake. Her dragon-covered hands covered her face, and her body heaved, up and down, in silent sobs.

So what, what does this mean? The son asked.

We can hope that she will pass gas, or go to the bathroom, which will mean her intestines have opened up. But if she doesn’t, then maybe we should think about comfort care.

Tears seeped through the dragon hands and hit the table. The sister with the pursed lips reached over. I passed a box of tissues.

How much time left if she doesn’t pass gas?

For someone who does not eat anything, I would say weeks to at most a month. I would suggest looking into hospice care.

For a while, we listened to the soft rhythm of the pursed-lip daughter rubbing the shaking back of her dragon tattooed sister.

What are you thinking? The palliative care nurse asked, finally.

“I’m thinking,” the dragon tattoo daughter finally moved her hands, exposing her red eyes and pierced nose “that you just told me Mom has only one month to live.”

Feel something, I told myself. This is as real as it can get. You cry watching movies, you weep reading books. This is happening right in front of you. Feel something.

I gave myself a little shake, but it was as if there was a thick shield of glass, separating me from the cloud of emotions stewing in the scene in front of me.

Is it possible, that I had already become hardened in the short 2 months, that others’ suffering no longer phased me? Or because nothing is registering anymore, after weeks of working and studying 18 hours a day?

I sat there, replaying the daughter’s words in my head, trying to squeeze something out of myself. But instead, I just watched as the son finally broke down, reached for the tissues, and the room was silent again.

Can we have some time? The pursed-lip daughter looked up at us as she silently comforted her two siblings.

“How do you think that went?” One of the palliative nurses asked as we stepped out the room.

“I think they took it well.” My resident replied, and turned to me “You should go look at her hernias though. They’re pretty impressive.”

So I did.

The patient looked comfortable as I sat down next to her. She smiled at me, told me she was feeling fine, and pulled up her gown to expose two melon-sized abdominal protrusions when I asked to take a look. Does it hurt? I asked when I lightly pushed on them. She shrugged. I stayed a while and exchanged some pleasantries. It felt comfortable and light, just like a conversation with any other patient.

It wasn’t until I walked out the room that I realized I had just been, for lack of better words, talking to an almost dead woman. And I knew that. But she didn’t.

That’s when the emotions washed over me, in such a rush that I couldn’t dissect them. It felt like a cloud of colors so complex, all seen for the very first time, all at once, that it made me dizzy.

So I sat down at the nursing station, and drowned in it for a while.

Let's Get Her Out

Last week I started my second Medicine rotation at a hospital near Flushing, Queens. For those who aren’t familiar, Queens is the most ethnically diverse urban area in the world. Pretty insane to think about.

I picked to come here, because I wanted to see a different world of medicine. Cornell, being in the Upper East Side (which apparently has the most expensive zip code in the world? Also pretty insane to think about [fact-check me tho]), anyway, you can imagine what the population is like here at the Cornell hospital.

So, Upper East Side --> Queens. Nuff said.

Here’s a story from my first week at Queens, which plucked me out of my shiny marble cocoon, and dumped me in a big pile of reality, at least for many.

“Let’s get her out of here this afternoon.”

The attending physician said one of his favorite phrases, as we presented the patient during morning rounds. Maybe because he is sick of this lady, or, more likely because there are 100 sick people in the Emergency Room of 60 beds, all waiting for days to get a bed upstairs.

The patient we’re talking about here is a 30-year-old, Spanish-speaking woman from Ecuador. She was actually the first patient I read about on my first morning at Queens. “Poor lady!” I had thought. She has had this mysterious abdominal bleed for a few years now, never bad enough to get her hospitalized, but also never obvious enough to be successfully diagnosed.

When we saw her, it became clear that she was suffering from more than just the puzzling bleed – she had patches of scaly, red, clustered rashes all over her chest, back, and leg. She did not look healthy. But there she was, quiet and cooperative, politely nodding and smiling as we asked her questions through the phone translator (she didn’t speak a word of English).

That was Monday.

Now it’s Tuesday. As in one day after she was admitted. We’re at morning rounds, where interns, residents, and attending physicians put their heads together to make plans for each patient for that day.

So the update is, yesterday we did an upper endoscopy on her (where we stick a camera on a long flexible rod down her throat into her stomach), and found that her entire esophagus (the tube that connects your mouth and stomach) is literally lined with actively bleeding, broken capillaries.

Found the culprit! I did an internal cheer.

“So yes, she can go, her blood tests are stable, let’s get her out of here this afternoon.”

I looked up, alarmed.

“Wait, but did we even figure out what caused all this bleeding to start?” I was confused – at Cornell, we would have kept the patient for at least one more week, running all different kinds of tests and consulting 30 different specialists.

The attending looked surprised.   

“Well you’re absolutely right.” He finally said, in a ‘let me see how I can explain to this naïve med student’ kind of tone. “we are going to discharge her without a diagnosis, because she’s medically stable, and she does not need to stay in the hospital. She can go home and follow-up outpatient at our clinics.”

That’s reasonable, I guess.

“Okay, although how do we know if she’s going to be able to come to follow-up? Do we know if she’ll have any barriers?”

On hindsight, I probably came off pretty annoying on my second day. They had a lot to do, and I was taking up time.

“Good point,” the attending clicked around on the computer. “I guess we could check what insurance she has.”

What a cool function. So we looked. And were silent for a quick second – Self Pay.

“Hmm. This doesn’t tell me anything. She might be undocumented for all I know.”

There was a moment of uncomfortable silence.

"This mean she'll have to pay full price on her clinic visits?" I was scared of the answer. That would mean hundreds of dollars per visit.

"Well, our clinic offers one complimentary visit after each hospitalization..." The attending replied. He sounded unsure himself. "well, we tried our best. This is unfortunate, but at least she’s here. In a year, we might not even be able to treat patients like her. We might be required to report them…with this new administration.”

We chuckled bitterly.

“Anyway, we’ll help make these follow-up appointments and tell her the time and location. Maybe for our own scientific interest we can send a few more panels of tests.”

“But she’ll still have to go today?”

“Yeah. Okay, send her labs, let her eat, and send her home on with antacids. Who's next?”

Ms. Betty

Disclaimer: The medical references in this story are made-up, as well as the name. The quotes aren't. I did my HIPAA training, I swear.

Ms. Betty was a patient I fell for, pretty quickly. But the unfortunate thing is, I don't know if the person I fell for was Ms. Betty, or who her dementia made her to be.

She was a teacher. Taught at PS 443, she would always gleam and say proudly. For how many years? I would always ask. Oh, way too many, would always be the response.

She got cranky a lot. A lot of yelling, about how nurses were trying to feed her poison (medicine). But I knew how to calm her down - "Ms. Betty do you like traveling?". "Oh, I traveled the world!!" Her face would always soften when she said that. "Of course, I can't do it anymore, but I went everywhere!".

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Ms. Betty doesn't have the capacity to make decisions for herself. Jenny, contact her nephew to get consent for an endoscopy.
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Ms. Betty was found confused and dehydrated in her bed at home by a concerned doorman, who had not seen this 93 year old tenant in 3 days. She lived alone, and had no family in this city.

"You're a medical student?" She looked up at me as I introduced myself over her hospital bed. "You know what my first choice career used to be?"

"Let me guess, could it have been....a doctor?"

"That's right!" She gazed off with a big smile, "I was pre-med, and I really wanted to go to medical school...but a job as a teacher was easier to find back then..."

"Wow that's funny!" I couldn't help sharing "I wanted to be a teacher! Almost didn't come to medical school, if you can believe it!"

"Oh that is very funny," she chuckled "We could've traded places!"

We stayed in that moment for a few seconds, smiling at each other. Then she exclaimed, "Anyway, these thieves just stole my money, my bag, and 4 of my canes! Find me my New York Times, will you help me?"
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Ms. Betty doesn't have the capacity to make decisions for herself. We need this procedure done.
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I held her hands as they prepared to poke a large needle in her belly. To take the fluid out.

"What is this, a circus?" Ms. Betty was displeased "I'm old, I don't need you to take all these heroic measures to save me. Whatever happens, happens. I don't want this."

"You'll feel a lot better after this, Ms. Betty."

"I'm old!! I'm never going to be like you again. You just have to accept it! If things hurt, I'll just have to accept that it's a part of the end!"

I didn't know what to say.

"Do you have any old people in your life?" She demanded.

"Yes, I do."

"Well talk to them, ask them what they want at the end. It's important."

And the needle went in.
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Ms. Betty doesn't have the capacity to make decisions for herself. She can't go back home. She has no family. We have to send her to a nursing facility.
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"Were you ever married, Ms. Betty?" We were trying to distract her as the nurse prepared her injections.

"Oh no." She replied "I had millions of children, though."

"Millions?" Here goes her confusion again, we thought, and exchanged glances.

"Yes. My students."

A New Project

Over the last couple of years I realized the importance of reflection.

I remember chilling on the hammock in my Boston backyard, getting over my quarter life crisis, and thinking, "Damn I'm lucky to have all this time to come to terms with my values, and the decision to go to med school."

I won't go into details there, but the point is I want to make time, often, to sit back and reflect on my experiences. On how they affected me, changed me, for better, or for worse.

Especially during this year - 2017 is going to be a year of endless learning and new experiences, because I will spend it in clinical rotations! It is arguably the most exciting, education, and exhausting year for any med student, so I don't want it to blindly go by!

I'll share stories here of moments that made me think. If you want, I'd love to hear what you think too. :)

P.S. A huge thanks to Peter for this wonderful idea! You're an inspiration in many ways.
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Time of death, 7:06.

Well, it was 6:49 first, but I guess they weren't ready to give up. There was still a hint of a heartbeat.

This was how I started my day this morning. I walked into the rounding room at 6:30AM, and before I could open my patient's chart, the intercom announced a code down in 2 South.

A "code" is a code used to announce a patient who enters cardiac arrest. When this happens, the designated medical team rushes to the beside in an attempt to resuscitate.  My intern was on that team, so I followed. I had never seen one before (!)

Things were already in full swing by the time we got there. A nurse was behind the bed handling the oxygen, which was blowing into his lungs. A tired looking resident was doing chest compressions while standing on a stool. A nurse had a syringe of epinephrine ready to shoot, on the order of another resident, who loudly took charge, and shouted directions with an unhesitant ring.

"Who's keeping time?" He demanded, "Take out your phone and start the timer" as he pointed to a doctor who had just rushed in. He did.

"XX, get ready to take over chest compressions, YY, get ready to step off!"

Now the room is steamy. No less than 20 people had crowded into this corner of the room, putting gloves on as they looked for ways to make themselves useful. On the other side, the curtain was being drawn around another patient staying in the same room (most rooms are not private, those are expensive).

"Check the pulse!" Two people on either side of the patient stuck their fingers out to do that. And my gaze switched onto the man on the bed. I could really only see his legs. which were pale and flabby, spread out wide, revealing a diaper in between. His chest rose and fell steadily in rhythm with the Oxygen he was receiving through a large tube. His eyes might even have been open. I couldn't tell.

He had a history of strokes, they said. Call his wife, they said, so a nurse rushed out.

The minutes passed as doctors lined up to take turns doing chest compressions, nurses filled syringes with different electrolytes and epinephrine, passed them to other nurses for administration, someone went and printed something useful, someone else kept a record of what has been done, shocks were delivered, machines were brought in, "are you sure there isn't a pulse", "shock one more time", "Clear!!"...

They really tried. They really did a good job.

Time of death was 7:06.

The crowd scattered, and mourned their way out of the narrow room in a silent, brisk file.

They have just completed another task for the day.

"What a way to start the morning, eh?" One resident said outside the room, as he pulled off his gloves.

"At least you're not that other patient in the room," said another, as they rushed off in their separate ways.

7:07, back to work.