Susanne Carpenter

Sorry 'bout the wait

Well 3rd year has come and gone and so have many experiences with death & dying. I apologize for such a long hiatus, but I'm back now and welcome your readership.

This year has brought much change for me in terms of career goals. Given the title of my last post, the reader may be shocked to know that I am going to be a surgeon. Yup, a little soul searching and a lot of honesty and next thing I know, I'm going into arguably the most physically and psychologically demanding specialty out there. Why? the reasons are many but suffice it to say it's the best thing for me and my patients. Don't worry, still going to be treating cancer patients and get tons of opportunities to be a missionary for end-of-life care and especially pain management and palliative care.

So, there are many interesting EOL care issues in surgery. I'll offer a few general insites here and delve more specifically in future posts. Many of our friends out there in the EOL care world view surgeons as the bad guys, the ones who don't know when to say "when", the ones who'll operate on anything that breathes. Not always so, but even when

Surgery Sucks the Life out of Us

Well, as you can see it's been quite a while since I've had a free second to jot down a few thoughts... though I've had quite a few worthwhile thoughts while retracting abdominal walls for hours on end. If you haven't already guessed, I'm currently on my third year compulsory surgery rotation. Don't get me wrong, I am thoroughly enjoying myself and the surgery residents are way "cooler" to hang out with than were the Internists who tend take themselves too seriously. But honestly, three months of Ins, Outs, and the same patient interview: "Good morning Mr. X, have you passed gas today? No? Okay, well thanks. We'll see you tomorrow."

What's missing in the above paragraph? Oh,  maybe awareness of anything other than myself and my enjoyment of surgery. That is exactly what many surgery rotations foster, a certain dehumanization that takes a once caring and comprehensive budding internist and turns her into a number crunching machine; taking in, processing, and excreting patients' lab values and bodily function quantities on rounds.

So, what does all this have to do with End of Life Care? Well, I was awakened from this number-centered, surgical stupor when as I finished one of my many brief patient interviews and was preparing to wisk myself away to write that she was "resting comfortably and has no new complaints," Mrs. H spoke softly, "Can I have a popsicle?" Slightly annoyed that I would no longer be the first one done with my note, I tracked down a poppsicle (at 5:30 am mind you) and stood over her, occassionally dabbing her face with a paper towel. We talked a bit and I immediately rediscovered my passion for patient care. We had bonded and I had a new friend, so imagine my surprise when I came in the next morning to find her "crumping out", gasping for breath with poor oxygen saturation and even worse BP readings, that were difficult to get due to her edema... things did not look good. She stabilized with the help of an oxygen mask, and avoided what would have been her 4th trip to the ICU. But things worsened drammatically over the next few days and she died alone in her room shortly after 4am three days after I had fed her a popsicle.

I am leaving out many details about her family and her condition and wound status in the interest of time and space, but the important part of the story is yet to come. When she died, nothing was done. A resident was called to pronounce her dead and the intern in charge was notified, but of course the eager medical student was not. So, imagine my surprise when I walked in for our morning chat, hoping to find my new friend awake and alert, only to find her very still, gazing out the window with one open eye, with the O2 mask still on her face. As I gloved up and approached her bedside, I offered a chipper "Good morning Mrs. H". Nothing. "Mrs. H?" I paused "Mrs. H?" I then astutely noted that she was no longer tachypnic... in fact she was not at all -ypnic. Suddenly overcome by a wave of fear, I rushed out of the room and approached my fellow 3rd year who had been on call the night before and said softly "umm, I think my patient's dead." She looked surprised but not about the news "Oh my goodness, I didn't see you come in. I wanted to page you but I figured you'd still be asleep. It happened about an hour ago." Somewhat relieved I asked, "what happened?"

"I dunno. Just know that the intern left the ER to go pronounce her."  I felt almost disappointed. It was so anti-climatic.  We had spent all this time praying for a DNR and hoping for her that this would be her last knock on death's door and then when it finally happened there was this cloud of guilt and indifference lingering in the air.

"Why isn't there a sheet over her head or anything?"

"I dunno."

"Should I go put one there?"

"I dunno."

"Okay, well I guess I'll go find another patient to pick up."

"Okay"

And that was that. Here I am, a leader in EOL care and it was too much for me to go back into her room, even just to pay her eyes and body the respect of being fully covered. What I would have done without extensive mortality-confrontation experiences I can only imagine, but as it was I still regret freezing up like that. Why couldn't I go back in there? What on earth was I afraid of? I'm not quite sure, but next time I'll act differently. Since Mrs. H's death, I have tried hard to make my daily BM interviews more personal, and have attempted to leave room and time for bonding and appropriately extended hospitality and patient care.  I just can't believe how much gets left undone. It is both inspiring and frustrating to see. I think this is where the dehumanization begins, when you have to let go of a nice lady's life and then turn around and go ask a drunk driver whether or not he's passed gas overnight. I'm not sure exactly how to combat this, or how to help others process similar situations, but I am doing my best to preserve my humanity with occasional conversations with non-medical people, playing with my dog, and reading the Chronicles of Narnia at bedtime.

Further news as events warrant and time permits.

AMSA Death and Dying Interest Group

This my first blog experience. I hope my personal commentary is exciting enough to spark change and inspire the hearts and minds of end-of-life professionals everywhere... but I'll settle for just a little extra attention. A little about me and why on earth a bright-eyed bushy-tailed 24-year-old medical student is and/or should be interested in death and dying: It is precisely because my fellow students are not expected to, nor are they comfortable enough to deal with end-of-life issues. Therein lie the missions of the American Medical Student Association's Death and Dying Interest Group: to enable and empower our peers to confront end-of-life issues in their own lives and in those of their patients.

Instead of "those who can't, teach", many of us budding pain management/palliative care/hospice physicians feel that "those who can should."  We want to make sure that those who can do and that those who can't either go into pathology, or learn at least the basics of dealing with end-of-life issues, caregiver stress, and referral to hospice.

So, how do we do this? And furthermore, what do we as medical students want or need to know about death, dying, and hospice?

Hopefully, this blog will address some of these issues. I'll offer a few quick answers generally for today.

First, medical students are frightened by and fascinated with death. We fear patient death in almost the same way we fear an exam... we know it will be scary for an hour or two, and we know there are certain things we can do to prepare, but after a certain point no amount of studying will improve our grade, and we just want to get it over with whether or not we fail miserably. And so, death becomes an obstacle to overcome rather than an experience to navigate. One thing that has helped my colleagues is exercises in defining death, physiologically and philosophically. Students somehow feel better with pathophysiological parameters of what's going on such that once they know exactly what will happen, they can then prepare themselves for possible emotions they will experience.