Strange things I've realized of late. For one thing, revelations always seem to occur when I work in the ICU. Let me be clear- I don't enjoy being in the ICU. It's not my thing, patients that are that sick and that tenuously sick- in the sense that they may, at any moment, turn the corner from sick to threatening to die. And yet, aside from working with cancer patients, the ICU is the only other experience I have with talking so openly and frequently about death.
A woman today said, "I don't know how you all do it," and it was meant to be a compliment, but I could not stop thinking about it as also a little bit of a criticism. The woman was the wife of a patient we were taking care of, who was not doing better, who had been quite clear about his intentions and wishes, and who we had just decided to extubate to let nature take its course. People have this impression that when you are "on life support," it is simply a matter of turning off the machine or taking the tube out, and then death follows. But like everything, it's not often that simple. I had just finished explaining what the process of taking the tube out would look like, what might happen afterwards, although we often can't even predict that. There is so much research out there in medicine, and yet that moment of death and dying remains mostly a mystery- people hang on unpredictably or pass just as unexpectedly.
But here's the other odd thing I've learned during the course of my residency. It's not really about what's happening, the details of it. As physicians, especially when we're in training, we have this tendency to fixate on that, the specifics of the problems a patient has and how we are failing at fixing them. This morning, the intern on the team presented the patient's problems and our plans while the patient's wife stood nearby. His wife then turned to me and said, "I didn't understand a word of that." After explaining to her what was going on, I went back to see her with the attending, and that's when we talked about his overall goals, and decided it was time to focus on his comfort. When she said, "I don't know how you all do it," she was grief-stricken and wondering how we saw such things regularly and treated it like a matter of course. I wanted to tell her that inside, it doesn't get any easier. That it haunts us too, that we couldn't make him better. That every patient we admit afterwards, we treat with all the more reverence, knowing how challenging healing can be in the very, very ill patient. I wanted to tell her too that sometimes I don't know how I do it either-- not in a conceited way but in the sense that I don't know why I'm not in therapy or in a deep depression over the things I have seen. Let me tell you- the ICU is 50% hopelessness, 25% idiocy, and 25% success. That's probably a generous estimate of the latter, by the way. I can't explain why, in the process of training, you learn to just deal with these realities of treating patients.
In the end I didn't tell her any of those things, because yet another thing you realize about death is that, as a physician, it's definitely not about you. Your job is to walk the balance between being there and staying out of everyone's way in those final moments.
Of course, then I go home and bake three dozen cookies, and realize that, oh, all of this does most definitely affect me. Which brings me to the much smaller realization which dawned upon me today. Lately, some of my friends/co-workers have been suggesting coming over to bake with me, or for me to come bake with them, and the thing is- I don't want to. I'm not trying to hide trade secrets or anything. It just occurred to me today that I don't really like sharing the process of baking with anyone because I find it relaxing, and it's one of those selfish things, almost like my form of meditation. I can't really imagine finding it so peaceful if someone else was there. Which probably says a lot about me and my attitudes about people, come to think of it.
Anyway, more navel-gazing at some future date. I have some more hopelessness, idiocy, and (hopefully) success to face in the morning.
A woman today said, "I don't know how you all do it," and it was meant to be a compliment, but I could not stop thinking about it as also a little bit of a criticism. The woman was the wife of a patient we were taking care of, who was not doing better, who had been quite clear about his intentions and wishes, and who we had just decided to extubate to let nature take its course. People have this impression that when you are "on life support," it is simply a matter of turning off the machine or taking the tube out, and then death follows. But like everything, it's not often that simple. I had just finished explaining what the process of taking the tube out would look like, what might happen afterwards, although we often can't even predict that. There is so much research out there in medicine, and yet that moment of death and dying remains mostly a mystery- people hang on unpredictably or pass just as unexpectedly.
But here's the other odd thing I've learned during the course of my residency. It's not really about what's happening, the details of it. As physicians, especially when we're in training, we have this tendency to fixate on that, the specifics of the problems a patient has and how we are failing at fixing them. This morning, the intern on the team presented the patient's problems and our plans while the patient's wife stood nearby. His wife then turned to me and said, "I didn't understand a word of that." After explaining to her what was going on, I went back to see her with the attending, and that's when we talked about his overall goals, and decided it was time to focus on his comfort. When she said, "I don't know how you all do it," she was grief-stricken and wondering how we saw such things regularly and treated it like a matter of course. I wanted to tell her that inside, it doesn't get any easier. That it haunts us too, that we couldn't make him better. That every patient we admit afterwards, we treat with all the more reverence, knowing how challenging healing can be in the very, very ill patient. I wanted to tell her too that sometimes I don't know how I do it either-- not in a conceited way but in the sense that I don't know why I'm not in therapy or in a deep depression over the things I have seen. Let me tell you- the ICU is 50% hopelessness, 25% idiocy, and 25% success. That's probably a generous estimate of the latter, by the way. I can't explain why, in the process of training, you learn to just deal with these realities of treating patients.
In the end I didn't tell her any of those things, because yet another thing you realize about death is that, as a physician, it's definitely not about you. Your job is to walk the balance between being there and staying out of everyone's way in those final moments.
Of course, then I go home and bake three dozen cookies, and realize that, oh, all of this does most definitely affect me. Which brings me to the much smaller realization which dawned upon me today. Lately, some of my friends/co-workers have been suggesting coming over to bake with me, or for me to come bake with them, and the thing is- I don't want to. I'm not trying to hide trade secrets or anything. It just occurred to me today that I don't really like sharing the process of baking with anyone because I find it relaxing, and it's one of those selfish things, almost like my form of meditation. I can't really imagine finding it so peaceful if someone else was there. Which probably says a lot about me and my attitudes about people, come to think of it.
Anyway, more navel-gazing at some future date. I have some more hopelessness, idiocy, and (hopefully) success to face in the morning.
