Death

One of my patients might die tonight. I think the chances are greater than not that she'll survive the night, but there's a real chance she might die. She has relapsing Burkitt's lymphoma and HIV, both diagnosed in September, and she has failed all of her chemo. She has only a short time to live (like, weeks), and I'm OK with that. What I'm not OK with is that I left this evening without being sure of what her wishes are. When she was admitted last night, she was a "full code" -- wanted everything done. As of an hour ago, she's a "DNR-A" -- "do everything except CPR." The attending signed the DNR order after talking to her. But I don't know if he actually talked to her about it. And I wouldn't even have thought to question it except for something the nurse said to me. (And in his defense, he had talked to the patient about it before, in the office, but the papers had never been signed. And I'm not saying that I think the patient actually wants CPR; she knows the extent of her disease as well and is very realistic about it.) But I didn't have the guts to go back into the patient's room and confirm with her in person that these were her wishes. Because she's already been crying all day, and I didn't want to see or hear her cry again. And that's what's bothering me about it. From a technical standpoint, if she dies tonight, it's not really my business, because the papers are signed and the orders are in, and I'm not there tonight to have to deal with it as it unfolds. From a guts standpoint, it IS my business, because I am one of her doctors now, too, now that she's in the hospital, and it's my job to talk about code status with patients, and I hate doing it, and this is a near-worst-case scenario of what happens when I try to ignore it. So if she dies tonight, I'm going to keep wondering if she really really truly didn't want CPR (even though I know this is objectively the best decision). And if she's alive tomorrow, am I going to be able to make myself talk about it with her?

Another woman might die tonight, too. She's in the ICU. She delivered her baby 6 days ago. She has swine flu. She's the third H1N1 case in our hospital this month; the first two died. All the cases have been obese, and all have had a history of asthma. But the first two I didn't know the name of, and no part of their care. This woman I found out about because everyone in the OB/Gyn department got an emergency page yesterday to go to employee health to get Tamiflu. Since I'm on medicine right now and not OB/Gyn and I wasn't exposed to her, I'm not at risk. But since I'm on medicine right now, I was around when the infectious disease team pulled her chest x-ray up on the computer this afternoon and I saw it. It's one of the worst chest x-rays I've ever seen. And then I asked the ICU team (which I'll be joining in one week), and they said she was intubated today and could seriously die tonight. I don't know why it's bothering me so much; all I've seen of her is a chest x-ray. But since she's post-partum, she could be one of my patients. And since she's in the ICU, she'll be my patient in a week, if she's still alive. I don't even know that it's her baby I'm thinking of (the first time I can truly say that I'm acting like a "mommy doctor" instead of a "baby doctor," as most people like to characterize the profession. I'm thinking about her -- the "sickest person in the hospital," according to one attending. And me.

Oh, hello

It's hard to pick back up when you haven't blogged in so long. I want to do a huge recap and tell all the crazy stories from the last two months -- TWO MONTHS! -- but that would be a novel in itself. And I have very little free time these days. So maybe it's better to just start back as though I never left. Even though that would be weird, too. So here are a few references to some of the things I would tell you about if I had all the time in the world, and maybe someday I'll come back and tell you about them for real.

• My graduation speech was awesome, thank you very much. I got the DVD in the mail last week, but haven't watched it yet.
• The two weeks between graduation and the wedding were crazy. Crazy fun, but still crazy.
• The wedding was amazing. I love looking at our pictures. I need to share the Flickr link with everyone.
• The honeymoon was amazing. We need to write it all down before we forget all about it.
• Moving to Philadelphia was not much fun. We were tired -- no, exhausted -- and packed everything up in 36 hours. Then drove 12 hours to Pennsylvania. The moving truck got damaged mysteriously, and of course, we had declined the damage insurance. We just got the estimate this week. It's bad, but we were imagining numbers in the 4 or 5 figures, so it's really not that bad at all, by comparison. I drove through the night, slept at various roadside stops, arrived at my mother-in-law's house at something like 6:30 in the morning, and slept for two hours before we had to wake up to go to our mortgage closing. We pushed through it, said hi to our new house, and went back to Downingtown to sleep all afternoon. We saw Up that evening, and I cried and cried and cried. There were a surprising number of touching moments, and I was just so emotionally drained that the tears kept flowing. "This is what residency will feel like," I thought.
• And now I'm a doctor! My white coat is ridiculously too big and I haven't had a chance to get it tailored. I took care of a former Eagle for a week, and I told him he needed to finish college. I've felt maybe 3 cervices, and have had no idea how dilated any of them were. I'm an expert in hypertension and diabetes -- which will be useful in OB/Gyn, no doubt -- but I know even less OB/Gyn than I did as a med student, because I'm spending my first two months on medicine/ICU. I've had three overnight calls so far, and a "good night" consists of an hour of uninterrupted sleep. I have not had to do CPR on a real person yet, and I have not delivered any babies. I haven't cried at work once (there was one almost time), and I haven't come home and cried since the first week. I've had two golden weekends (this is #2) and no black weekends, and I've come very close three separate times this week to discharging all of my patients, which would mean I wouldn't have to come in the next day. Each time, though, the patients foil me at the last minute. Oh well.
• Our house is 85% set up, which means it's very functional. It's not completely put together, though. We have lots of little projects, and some big projects. In some ways, we have less space than we did in Louisville, and in some ways, we have more. The net effect is that we will still need to get rid of some stuff, so that's happening slowly.

And I think that's it for the updates. If, next week, I all of a sudden tell you a good medical story (I know you like them, after all, and I've got some good ones!), I'll consider it fair, since I've now updated you, and you know I'm an intern in Philadelphia, and no longer a med student in Louisville.