Gone too long

So my friends and fans, has absence made your hearts grow fonder? Have you found yourself pining away for a new post of the mundane misadventures that fall my way?

I didn't think so either, but, after a trip into the ether, I'm back. Where I've been, now there's a tale. Like Mr. Baggins, I feel like I've been there and back.

When you first put on the long white coat, you feel like a superhero donning his new supersuit. Like the Prince of Gotham, your utility belt is equipped with pager and PDA, a stethoscope hangs over your shoulders like nunchuks and you walk with a just a hint of a swagger (that is totally unearned). Bring on diabetes, you think, it's game time.

Of course, the bubble is quickly burst once you actually start seeing patients. The "simple" diabetic now shows up with a sky-high sugars, dangerous levels of potassium and dehydration. Now you can't just say, "give him insulin." You gottta figure out what kind of insulin, how much and for how long. Back-seat driving, as pleasurable as it was as a student, just doesn't work here.

One of the things I was least prepared for was the physical and emotional drainage of internship. Especially nights when I was on call, it felt like being given the steering wheel of the Batmobile in the middle of a car chase. All you really hoped to do was avoid crashing...

Of course, it's not so dire - you do have senior residents and attendings for help and guidance. Plus I have this tendency to stay and stay until I think everything's done, which makes for some super long days. I've learned that "signing out" (giving the on call person tasks to follow up on) is not a sign of weakness, but rather of sanity.

There are a couple of memories that stick out in my mind. One is the first time I had to pronounce a patient's death. The patient was 41 years old and was diagnosed with melanoma (a skin cancer) this past April. Unfortunately, the cancer had spread all over his body, and there were metastases in his heart, liver and brain. When he came to the hospital, he knew that he didn't have much time left. What he needed from us was placement of a catheter to drain fluid from his belly (ascites secondary to malignant effusions in medical jargon).

I did an initial tap of the fluid in the patient, to relieve his symptoms, until a catheter could be placed by radiology in the morning. The next morning, however, things had changed. His kidneys were shutting down, his heart was going into dangerous rhythms and it became clear that the end was coming sooner than later. The patient did not want any heroic measures taken, something his family was in agreement with, and asked only to be kept as comfortable as possible.

When they paged me to come and pronounce his death, his entire family was at his bedside, his wife in tears and young children around the bed. He was diagnosed with melanoma in April and dead in August. I remember feeling clumsy while examining him for signs of death. It sounds strange to say that, but in medicine, death is still a clinical diagnosis. There are a series of things you look for on exam to confirm the patient's death and then you "pronounce" them.

But more than that, there is an emptiness you feel, no matter how many people are in the room with you. The same person you were talking to earlier in the day now lies before you, lifeless, and there is no more you can do.

Death lives in the shadows. We fill our hospitals with gleaming electronics, bright lights and windows as though we can drive out the shadows, drive out the only certainty there is in the world, that we too shall pass.

As difficult as it was for me to deal with, I cannot even imagine how it must have felt for the patient and his family. How does one wait for death?

On those weighty words, I leave you to your thoughts. Until next time friends...