When Doctors Are Wrong

As medical students and resident physicians gain experience they also gain
knowledge and confidence. Consequently, young trainees eventually reach a
level of comfort in speaking with families and patients about prognosis and
disease course. This is part of the purpose of training, as these
conversations happen so often that they are an integral part of practicing
medicine. But it isn’t certain that with experience and confidence also comes
accuracy.

***

Soon after finishing sign-out on a night shift I received a page. The
nurses told me that a patient’s daughter had arrived and wanted to speak
with me about her father. The patient was an elderly but relatively healthy
gentleman who had been admitted with abdominal pain. Multiple imaging
studies had shown little to account for his discomfort. But the pain was so
intense that he could not eat anything. Even going to the bathroom was
difficult — he held in his stool to avoid the agonizing act of defecating.
As a result, he became constipated, which then exacerbated the pain. Thus,
the medical team administered anti-inflammatory treatments, stool softeners, and IV
fluids as they searched for the etiology of this troublesome symptom.

The patient’s daughter asked me about the latest imaging studies and labs
as she sat holding her father’s hand. Buried to his chin under the covers,
the patient participated in the discussion, asking when he would be able to
eat and go to the bathroom easily again. I explained that all the tests had
been negative so far and we were unsure of what was going on. I then left the
room, and the daughter caught up to me in the hallway. She seemed worried,
speaking hurriedly and pleadingly: “How long do you think my father has
left to live? How much time do I have left with him? Should I start making
funeral arrangements?”

The questions took me aback. I had seen plenty of patients in the
intensive care unit
who were on the verge of death and they looked so different from her father
— a profound pallor, somnolence, lethargy, disinterest in conversation
and food. But this patient wanted to eat again, he wanted to see his
family, he wanted to watch basketball on TV, and he was interactive and
conversational. His cheeks certainly did not exhibit the deathly pale hue
of those crossing over to the other side. I assured the daughter of this:
“I don’t think you have to worry about that. The most important thing right
now is that we figure out what is going on. I can’t tell you how long he’s
going to live but I would be shocked if he had only days or weeks left.”

This interaction repeated itself for the next three nights, always with the
same diagnostic uncertainty. On further imaging there was evidence of some
abnormal fluid in the abdominal cavity. Interventional radiologists
extracted the fluid to test it for any cancerous or infectious cells, but it
would take perhaps a week or more for definitive results to come back. In
the meantime, the patient’s pain improved and he moved his bowels without
issue. Even though we didn’t yet have a diagnosis he seemed to be doing
incrementally better each day.

On the fourth night I again saw the daughter and she asked: “You don’t
think I should be planning the funeral for my father, do you? He’s not
going to pass in the next few days?” I understood why she was asking the
question — any child ought to be concerned for the well-being of a parent.
But I was also surprised because her father was on the mend. I told her
that if he continued to improve he would leave the hospital, and his primary
care doctor would follow up the lab results and see him in clinic.

At around 2 a.m. that same night, a voice over the hospital loudspeaker
echoed throughout the halls as I jumped out of my chair: “Code blue, 7th floor, code blue, 7th floor.” There was a
patient in cardiac arrest. I ran out of the workroom and met up with
another resident. Which patient was dying? On my way to the code I ran
through the patients on the coverage list that evening; I did not expect
anyone to pass away. As the other resident and I ran down the hall I saw
the code cart containing all the medical resuscitation equipment necessary
to treat cardiac arrest outside of the room I had visited every night for
the past four nights. My heart leapt out of my chest; I pleaded with some
higher power that it not be that patient. But it was.

The resident, nurses, and I immediately began CPR. The anesthesiologists
burst into the room and stuck a tube down the patient’s throat and into his
trachea to protect his airway as the respiratory therapist attached the
tube to a ventilator to help the patient breathe on his own. After multiple
rounds of CPR, his pulse returned. We wheeled the patient — attached to
tubes, and poles filled with intravenous fluids — to the ICU for closer
monitoring. He didn’t respond to our questions or poking and prodding, but
he was alive.

Alas, as soon as we got to the ICU, his heart once again
stopped beating and his IV line ceased working — his veins (which can
happen as we age) were friable and brittle, and the small vein carrying the
volume and force of the IV infusions burst. Without an IV we could not give
medications. We turned, then, to an

intraosseous (IO) line
. This entails drilling a hole into the bone and infusing medications
through that hole. It is a proven method of administering medications when
physicians and nurses cannot obtain IV access. I opened the IO kit and
attached the drill to the IO needle, placing it on the shinbone and drilling. It
slid into the bone, I detached the drill, and hooked up the
IV tubing to the IO line jutting out of the patient’s bone. At this point,
the code had been going on for nearly 15 minutes and the patient’s family
had arrived. They watched as we furiously attempted to revive their loved
one. At some point a family member shouted “Stop, please, enough!” Time of
death: 2:45 a.m.

I sheepishly held my head down, avoiding eye contact with the family as
they sobbed. The medical team and nurses quietly left the room, leaving the
patient in peace. As I passed by the daughter, I could only say “I’m so
sorry” — little else would have sufficed. Not only did we not save him, but
night in and night out I had given the daughter a false impression that he
wouldn’t die. Perhaps, I wondered, I had been disingenuous in some way.
Either way, I was wrong.

 ***

Alas, physicians are wrong relatively often, and there is ample
evidence for this. In a systematic review in the

British Medical Journal in 2012
, researchers found that each year up to 40,500 adult patients in American ICUs die with a misdiagnosis. The Journal of the American Medical Association published an analysis in 2009, concluding, among other things, that “while the exact prevalence of
diagnostic error remains unknown, data from autopsy series spanning several
decades conservatively and consistently reveal error rates of 10% to 15%.”
The American Journal of Medicine published a

separate analytic review article in 2008
, concluding that diagnostic error occurs up to 15% of the time in most areas
of medicine. The authors further theorized that overconfidence often
accounts for at least some of the errors. These reports have reached a wide
audience in the laymen’s press as well. In 2015, the Washington Post published an article indicating that diagnostic errors affect 12 million adults each year. The
impacts of errors, as we see in the story above, don’t just involve the patient
but the patient’s families, too.

Though these statistics are shocking, it is almost impossible, from the
patient perspective, to look at them and subsequently be skeptical of everything a doctor says. After all, we are not only practically but also emotionally dependent on them: We want reassurance from our
physicians and we want definitive answers. As a patient, it is frustrating
to hear “It may or may not be cancer and we can’t be sure” or “I don’t know
how much longer she has left.” Indeed, when the path ahead of us is no
longer clear, we turn to physicians for answers because of their
experience. We want them to be the kinds of people none of us can
be — always right, always knowledgeable, always calm and composed. But they
are fallible, despite the impossibly difficult and long road they’ve
traversed.

And what can we as physicians take away from this? Doctors want to be
the kinds of people their patients expect them to be. But the statistics
of medical errors are the reminders of how impossible that is; how many years of studying and
experience are necessary even in order to be competent; how difficult,
despite the many exams we take and pass, it is to apply knowledge
appropriately. Not only are we fallible, but the science we rely on is not
always helpful either. Indeed, the best studies are useful merely for inferring what will
probably happen — they do not tell us definitively what will happen to the
patient in front of us. Moreover,

scientific evidence does not exist
for every treatment in every situation or every diagnosis in every
situation. Once again in medicine,

our ideal does not match with the real
, and our preconceived notions are sometimes shattered in moments of frustration
and uncertainty. Perfection is unattainable, but we must
constantly seek it out, always aware of how out-of-reach it lies.

When patients and their families now ask me questions about prognosis or
treatment I always preface what I say with: “Nothing is 100% in medicine.”
Though I will be wrong again in my career and will, hopefully, learn from
my mistakes, I never want to give a false impression. We often tend to ignore uncertainty or wish it away, but we must always remind
ourselves, whether as patients or doctors, that no doctor and no science is perfect.

The Distortion of “Death with Dignity”

I recently wrote a short essay for Public Discourse about the “death with dignity”
movement. In the piece, titled “All Death is Death Without Dignity,” I compare the palliative-care movement — which seeks to alleviate the physical pain of death, often in the context of hospice care — to the physician-assisted suicide movement and
find the differences in their respective descriptions of death telling. I quote somewhat extensively from the piece here, in order to then offer some additional thoughts on why the phrase “death with dignity” is a problem.

It has become common to talk of “death with dignity” in the policy world. There’s a

Death with Dignity Act in Oregon
, which permits physician-assisted suicide. There’s a

Death with Dignity Act in Washington
, which also legalizes physician-assisted suicide in certain circumstances. A Death with Dignity National Center exists in
Portland, OR, a nonprofit that advocates for patients to “make their own end-of-life decisions, including how they die” — its website is plastered with
images of smiling faces. The message, it seems, is that if one can control how one dies or when, the dying process is somehow less disturbing, awful, and
humiliating. Instead, it can be dignifying.

Conversely, when dealing with end-stage cancer patients and palliative-care physicians in the hospital I rarely hear the “death with dignity” phrase used;
more often I hear a palliative-care doctor say, “we want him (or her) to be comfortable.” It is a marked difference between the palliative-care movement
and the assisted-suicide movement. In hospice, there is a resignation to the uneasiness and difficulty that comes with any death. With palliation, nurses
and doctors can only free the patient from pain but not from the indignity of dying.

And why does choosing the way one dies have no relevance to whether or not a death is dignified?

Death is not simply a part of life but the end of human life — the end, in some sense, of an entire world. It is the transformation of a living member of our
species into an immobile mass of flesh with no potential for life again. Rabbinic Jewish authorities recognized this in the Mishnah, an extensive
commentary on Jewish law, when they wrote,
“anyone who destroys a life is considered by Scripture to have destroyed an entire world; and anyone who saves a life is as if he saved an entire world.”
Thus, not only are the physical manifestations of death ignoble and viscerally disturbing but, in principle, the end of an individual is tragic, too….

Death and dying detract from life by ending it. There are more or less disturbing ways to pass (you can die while someone is breaking your ribs doing CPR
or you can die without that), but none of them is truly dignified. And choosing to preempt death using physician-assisted suicide doesn’t change this. In
truth, there is no such thing as death with dignity. There is only somber tragedy, as your body lies exposed to the world’s Hobbesian bacteria and insects.

I think there is an important debate to be had about whether assisted suicide should be available in certain, very rare circumstances. But that is a
separate discussion from the point I am making here, which is that the term “death with dignity” is inaccurate and misleading. The phrase changes our whole
concept of death — it is a change that puts a positive spin on dying, a change that detracts from the somber aspects of the end of life.

Wikimedia Commons

This deceptive use of language reminds me of George Orwell, who focused some of his sharpest criticism on the use of language and how it changes our
perception of events and ideas. In his famous 1946 essay “Politics and the English Language,” he condemns the “tendency of modern prose … away from concreteness.” Specifically, Orwell exposes the misuse of euphemisms common in war propaganda — for instance talking about sending people to prison and death camps as the “elimination of unreliable
elements.” Euphemisms can obfuscate the gravity and odiousness of an action, thus creating a false appearance so powerful that it can become tolerable, even appealing.

In 1984, Orwell offers a similar warning. The totalitarian government of Oceania uses its own language called Newspeak, destroying
most of the English language to make way for abbreviations and vague terminology — “cutting the language down to the bone.” As one character explains, “the great wastage is in the verbs and
adjectives, but there are hundreds of nouns that can be got rid of as well.” By manipulating the language, the government of Oceania manipulates the way people think, specifically the political and moral decisions they make. One of its most effective tools is the creation of catchy slogans that utterly distort reality: “war is peace,” “ignorance is strength,” and so forth.

I am not saying that the “Death with Dignity” movement
is an attempt at mind control, like in the police state of 1984. Nor am I arguing that there is only one right way to express an idea. But when it comes to framing an argument
or the context of a debate, we should be very careful when we use language that assumes certain principles that subtly distort reality. In this particular case, the phrase “death with dignity” assumes that death can be dignifying. At its core,
however, death is nothing less than awful:

Indeed, the concept of “death with dignity” is a euphemism for what is one of the most heart-wrenching, difficult, unsettling, and undignified events of
human existence. I think of that patient who chose to make his death comfortable and the image is disturbing rather than heartening. Where is the dignity
in lying in a bed with flies buzzing around one’s head, vulnerable and lifeless?

Revisiting The House of God

Dr. Stephen Bergman, a psychiatrist, published his now-famous satirical novel The House of God under the pseudonym Samuel Shem in August 1978. The book’s protagonist, a young intern, describes the emotional and physical difficulties during the first year of residency. With more than two million copies sold, the work is something of a classic within the
medical profession.

Even in medical school, before we started our clinical rotations during our third year, some of my
friends and professors recommended I read the novel, so I borrowed it from a fellow student. I enjoyed it but couldn’t fully identify with the
characters in the story, which dealt with the hardships of residency: terrible hours, unsympathetic attending physicians, obstreperous and ornery patients, horrible deaths, and flailing personal relationships outside of the hospital because of the amount of time spent inside it. As a student, I hadn’t yet seen
these things and from the outside this all seemed unrealistic: How, I asked myself, could this even be close to the reality of a modern academic hospital?

Now that I am through my third and fourth years of medical school as well as my first year of residency I have re-read the book, and I thought it would be
interesting to reconsider my initial impression. Indeed, the novel is so much more relevant to me now. In order to illustrate this, it is worth looking at
just a few passages.

I got more and more tired, more and more caught up in the multitudinous bowel runs and lab tests. The jackhammers of the Wing of Zock had been wiggling my
ossicles for twelve hours. I hadn’t had time for breakfast, lunch, or dinner, and there was still more work to do. I hadn’t even had time for the toilet,
for each time I’d gone in, the grim beeper had routed me out. I felt discouraged, worn. (p. 41)

Though slightly hyperbolic, all this is scarily familiar to me. On some days there is so much work to do that one doesn’t really have time to sit down and
eat. Or, when one does finally have a spare moment (after 6 or 7 hours of running around), animal instincts take over and without being cognizant of
it one ravenously attacks any food available. Some of us stick granola bars in our white coat pockets to prevent this sudden and unfettered hunger attack
but even this is just enough to make us want more. Occasionally, the issue is that one forgets to eat and when we smell the trays of food being
delivered to hospital rooms during lunchtime, our intestines do somersaults, squeeze, shiver, and groan as we are reminded of our baser needs. We experience
pangs of hunger that occur throughout the day because meals, and even glasses of water if one has time for them, are far apart. I have, in multiple instances, come home at night or in the morning and stood for a moment in the kitchen while having an internal debate with myself: Am I more tired or
hungry?

And Shem’s line about the “grim beeper” made me laugh out loud. I remember twice walking into the bathroom to answer the call of nature, when suddenly the shrill sound from my pager or phone prompts me to abort the mission, walk out, and
answer the other call.

The talk was, on the part of the doctors, all medicine….

The accuracy of this is stunning. When residents get together or when we have a spare moment to chat at work, we don’t usually talk about politics or
friendships or relationships so much as we talk about medical stories. We trade tales of difficult procedures or illnesses or we tell hilarious medical jokes. Friends who spend time with us
outside of the hospital are shocked at how much we speak about work with each other. But a resident’s life revolves around the hospital. We (almost)
literally reside at the hospital and the eventful aspects of our lives usually occur in the healthcare setting. As one can see from even a quick glance at
some posts on this blog, medicine is filled with human drama, humor, sickness, death, and life. How do we avoid talking about all that in our spare time?

The House of God found it difficult to let some young terminal guy die without pain, in peace. Even though Putzel and the Runt had agreed to let the Man
With Agonal Respirations die that night, his kidney consult, a House red-hot Slurper named Mickey who’d been a football star in college, came along, went
to see the Agonal Man, roared back to us and paged the Runt STAT. Mickey was foaming at the mouth, mad as hell that his “case” was dying…. Mickey called a
cardiac arrest. From all over the House, terns and residents stormed into the room to save the Man With Agonal Respirations from a painless peaceful
death. (p. 245)

These can be traumatic moments, indeed (I have written about coding patients herehere, and here). Shem’s point is that we in the hospital sometimes do
chest compressions on patients we surely will not be able to resuscitate or, if they are resuscitated, will be dependent on a ventilator and unconscious
for the remainder of their days. Do we try to revive a 90-year-old with metastatic cancer to the spine and brain? Or do we try instead to make the patient as comfortable as possible?
From the patient’s side (and the patient’s family’s side) the difficulty, which seems insurmountable, is in accepting the end. For most physicians, like the
narrator of The House of God, the difficulty lies in cracking ribs and sending electrical shocks through someone’s body with no clear purpose. In fact, we
frequently ask families to let us make their loved ones comfortable, at least, before they pass away. But that is not always the decision that is made.
And in the passage above Shem satirically chides those who believe the best course is always to be as aggressive as possible.

Eat My Dust Eddie, being run ragged in the death-house, the MICU [Medical Intensive Care Unit], looked awful, and was talking about his previous night on
call: “I was admitting my sixth cardiac arrest and I got this call from the E.W. — Hooper, it was you — saying that there was a guy down there who’d
arrested and you were thinking of sending him to me if he survived. I hung up the phone, got down on my knees, and prayed: Please, God, kill that guy! I
was on my knees, I mean ON MY KNEES!” (p. 126) 

My colleagues and I have never wished that anyone would die. But, undoubtedly, we all identify with the feeling of being overwhelmed. When you’re exhausted
and still admitting patient after patient and trying to work them up for a new diagnosis while also taking care of other patients on the service, writing notes,
fielding pages or phone calls from nurses, drawing blood, and doing CPR, there are moments when it feels as if there is no more time or effort left to give.
You are working with rope with no slack or trying desperately to tread water. This is especially true in a place like the Intensive Care Unit, where patients are sicker
and require closer monitoring. During those moments, we beseech the hospital gods: “please, no more admissions, please no more.” Or, “please don’t let
anyone get sicker than they are.” It’s not every day one feels this way, but it is often enough that the sentiment is familiar.

*   *   *

When The House of God was first published it was not received well by Dr. Bergman’s colleagues and peers. As he tells it,

… my book The House of God enraged many among the older
generation of doctors. I was maligned and disliked. The book was censored by medical school deans, who often kept me from speaking at their schools. None
of it really bothered me, though. I was secure in the understanding that all I had done was tell the truth about medical training.

Thus, the book is not only a brilliant and witty piece of satirical literature, it is also a “fiction of resistance,” as Bergman describes it. Its most sinister and clueless
characters are the ones in charge. And in many cases their worship at the altar of medicine and science damages their relationships with patients,
residents, or each other.

Much has been written about this aspect of the book in recent years: Dr. Howard Brody of the University of Texas Medical Branch

wrote about its relevance in the American Medical Association’s Journal of Ethics in 2011
. Dr. Suzanne Koven, a primary care physician,

interviewed Dr. Bergman about the book for the Boston Globe in 2013
. Dr. Howard Markel, a professor of pediatrics, psychiatry, and the history of medicine at the University of Michigan, discussed the book in a piece for the New York Times in 2009.

The reason for this interest may have something to do with a story Bergman tells in his own 2012 piece for The Atlantic:

And then one day I got a letter forwarded from my publisher, which included the line:
“I’m on call in a V.A. Hospital in Tulsa, and if it weren’t for your book I’d kill myself.”
I realized that I could be helpful to doctors who were going through the brutality of training. And so I began what has turned out to be a 35-year odyssey
of speaking out, around the world, about resisting the inhumanity of medical training.

But the culture in medicine has changed dramatically since this book was written. Institutions are far more humane than they once were. Nevertheless, what we see and how much we need to see cannot change. Doctors ought to be exposed to a wide range of pathology; they
must be exposed to death. This is how one learns to be a great doctor, to diagnose obscure diseases, to treat common diseases successfully, and to save
lives during a hectic code in the hospital.

No matter how authority figures treat residents, Bergman’s book will always be precious to future generations of doctors. Like any great novel it identifies common yet significant human experiences. The author tells us, as it were, that “yes, I know
exactly what this is like and I laughed at the same things you did. I made the same mistakes. I had the same
difficulties.” Such commiseration ameliorates that unsettling feeling residents experience: the feeling that the hospital is a rabbit hole
that spirals into a detached and harrowing yet hilarious world. And, because of The House of God, there will always be a shared understanding
among residents and readers of the triumphs and tragedies accompanied by this feeling.

Managing Expectations

“Yes. But could I endure such a life for long?” the lady went on fervently, almost frantically. That’s the chief question — that’s my most agonizing
question. I shut my eyes and ask myself,
Would you persevere long on that path? And if the patient whose wounds you are washing did not meet you with
gratitude, but worried you with his whims, without valuing or remarking your charitable services, began abusing you and rudely commanding you, and complaining to
the superior authorities of you (which often happens when people are in great suffering) — what then?

Fyodor Dostoyevsky, The Brothers Karamazov

I have a collection of idyllic memories from my childhood summers, traveling with family to the sleepy New England town of Lenox, Massachussetts. There we
would go hiking, watch movies, attend concerts by the Boston Symphony Orchestra at their summer retreat in Tanglewood, and swim. And we never failed
to visit the Norman Rockwell Museum in Stockbridge. Rockwell was one of the most well-known American painters
of the twentieth century and some of his famous works appeared on the covers of the Saturday Evening Post. His humorous, sentimental, and occasionally somber paintings capture everyday American life during the early and mid-twentieth century, portraying families eating dinner, children arguing about a basketball game, and teenagers at a lunch counter.

Norman Rockwell, Doctor and Doll (1929)
Curtis Publishing

One painting in particular sticks out in my mind, Doctor and Doll, drawn for the Saturday Evening Post cover of March 9, 1929. A dapper physician in a suit and tie sits in a chair. A young girl in her winter clothes with a hat,
scarf, and mittens scowls at the doctor, reluctant to let him examine her. She’s upset, as so often children are, to be seeing a physician. She holds her
doll up to him as he gently pretends to listen to the doll’s heart with his stethoscope. He plays along with the young girl, earning her trust so that he
can, perhaps, listen to her own heart next. The doctor does not look down at a note or a chart while taking care of his patient. He’s not
rushing to leave. He merely attempts to establish trust and takes the time necessary to earn it. It is the paradigmatic image of what we want a doctor’s interaction
with a young patient to look like, an idealistic portrayal. And Rockwell realized that this was true of many of his paintings. He
once said: “The view of life I communicate in my pictures excludes the sordid and ugly. I paint life as I would like it to be.”

But hyperbole, though an artistic
strategy, is not always evident to children on family vacations. While the Rockwell painting does not
exactly illustrate my expectations of medicine, it does exemplify a certain naïveté with which I approached medical school. I knew I would work incredibly
hard and I also knew, after reading firsthand accounts from several physicians, that I would see horrible things. However, I retained some of that boyish
optimism about medicine and imagined that the majority of my interactions with patients would be as depicted in Rockwell’s painting.

Since then, however, much has changed. I was recently chased down the hall by a psychiatric patient who had a low sodium level (which can lead to seizures).
We needed to get a sample of his blood to recheck his electrolytes, but he refused and when I tried to explain to him why we needed to get labs, he jumped
out of bed and ran after me, saying: “I’m going to f***ing show you how I do things.” Another patient recently told me “I don’t need to f***ing be here” and ran out as I chased after him. I have been called an “idiot” and a “fraud.” I have also been screamed at, given the middle finger, and physically threatened. Yet another patient threatened to report me to the New York Times because his room
was too hot. I have tried convincing countless numbers of patients (sometimes successfully and sometimes not) to take life-saving medications. I
saw a patient fall out of her bed, micturate on the floor, and go into cardiac arrest. Another patient threatened to slap me after I ordered an
EKG to examine his arrhythmia more closely. There have been
times when I have had to choose between spending time writing notes and speaking with patients and their families — and have paid the price for choosing the former. I have performed CPR more times than I’d like to think about. And there is, I am certain, more to come.

None of this is evidence that I have come to dislike practicing medicine. I selectively edited out the brighter episodes to make a point:
medicine is a universe away from what most of us perceive it to be. It is far more dark, depressing, and quick-paced than anything I imagined. It is, in short, messy.
But I believe it has always been this way. Samuel Shem’s The House of God, published in 1978, is a satirical novel filled with familiar yet horrific stories and
bizarre interactions that characterize a physician’s first year of residency. (I’ll write about this book in another post.) That experience of some forty years ago is hauntingly similar to my own. The passage at the beginning of this post from The Brothers Karamazov, completed in 1880, resonates with me as well.

Residency has altered my expectations. Humans have always been sick and will probably always face sickness and death. And sickness and death are deeply unsettling experiences that sometimes prompt strange
and disturbing behaviors. They challenge our youthful notions of invincibility and immortality. They expose our weakness and decrepitude and force us to
confront an end that none of us can face with a straight spine. A hospital lays bare these notions — and the whole experience makes it difficult to be calm, reasonable, and
understanding. Who can be levelheaded in this perpetual twilight?

For that we must return to Rockwell’s comforting painting, a glorified image of what we want from medicine. If we look closer we may see the painting differently.
The doctor has made little progress with his patient. The girl has not removed her hat, scarf, or shoes. She has not yielded one bit. She merely lets her doll be the “patient.” And yet the doctor readies himself to do whatever it takes to help her. Almost imperceptibly smirking, he patiently listens to the doll’s
chest. He is not angry or frustrated but sympathetic. Perhaps we can face the daily frustrations of the hospital better with some of that Rockwellian spirit to strive for life as we would like it to be.

Becoming Cynical, Part 4

I have written quite a bit about why physicians become cynical (see herehere, and here). What follows are some more thoughts on this topic
that relate to my previous post on Parkinson’s Disease (PD).

Recently, a sixty-three-year-old patient came to the neurology clinic for a left-handed tremor that had become worse. He and his wife gave a classic history of the
onset of PD. His tremor occurred only at rest. He felt his left arm was weaker than his right arm — this was evident in some sessions with his personal trainer. He noticed his handwriting had become slightly smaller. And his wife said she couldn’t hear him well anymore.
She initially thought it was due to her own hearing loss, but her friends also found that his voice had become harder to hear. The attending physician and I asked other questions
regarding sleep (sometimes PD patients act out their dreams), drooling, and cognitive status. After a physical exam, a cognitive test, and some more
questioning, the attending physician concluded that the patient had PD.

At this point in my short career I had seen multiple patients with PD, some in its early stages, some advanced, and some in-between.
I was at least superficially familiar with the course of the disease. So when we broke the news to the patient and his wife, it felt slightly banal:
another PD patient, another diagnosis, and another prescription for PD drugs.

Shutterstock

But this patient’s reaction took me by surprise. Most people are upset, ask for some information about the disease, take
their prescriptions and leave. But in this case, the patient’s questions were far more detailed than I was used to (the attending, given the extent of
his experience and knowledge knew exactly what to say). The conversation eventually led to a discussion about the advanced stage of the disease. We explained
that medications and deep brain stimulation would become less and less effective. Ultimately, he would get dyskinesias and end up in a wheelchair.

We all know we’re going to die — that is one of the few things in medicine that one can say is 100 percent certain. But there is something eerie about hearing
exactly how you’re guaranteed to deteriorate. The attending was telling the patient in a very diplomatic way that his life would look just so in about twenty
years. It was said gently, but the patient understood the meaning well. His wife began to cry and he teared up, too. His movements, his hobbies, and control
would slowly peter out and vanish.

After I told this story to someone with experience in the medical field, the person responded with, “I don’t know what they’re so upset about — it’s just
Parkinson’s Disease.” This probably seems callous and insensitive. Just PD? Think of the horrible symptoms, the side effects of the medications, the
creeping debilitation. Imagine, eventually, being locked-in, frozen and unable to move, relying on a pill that becomes less and less effective for allowing such simple functions as turning
around or walking. It is indeed a terrible disease.

But for a physician who has seen far worse — such as ALSCreutzfelt-Jakob diseasetrauma, Sudden Infant Death Syndrome (SIDS), all of which involve rapid debilitation and death — PD can seem preferable, with its long course and all the available treatments, however limited they may be.

This tendency to compare the severity of varying illnesses is perhaps one of the greatest traps in practicing medicine. Physicians see so much that
diseases that are serious to most patients seem mild relative to the more horrifying ones. I have found myself falling into this pit more than once. I remember
doing CPR on a patient who had burst a pulmonary artery (a major artery in her lungs) as a complication of her lung cancer. As I did chest compressions, blood poured out of her mouth and onto my pants, soaking my shoes and scrubs. While this was going on, I got
a call from a nurse about a patient with a history of drug abuse who wanted more pain medication. He may very well have been in serious pain. But compare
his needs to this woman’s death. Clearly, one was much more affecting, disconcerting, and significant than the other, and it was a while before I
could address the drug patient’s pain appropriately. It can be all too easy to dismiss as a “mild” disease or complaint the sorts of conditions against which our exposure has hardened us.

Thus, with experience, our expectations change; it takes more to move us. We shrug off the majority of hospital cases as “not that bad” or “benign.” I think
all this is inevitable in a career in medicine. One must pinch oneself every day, at the very least, to recognize it.

CPR in the Hospital, Part 2

With what strife and pains we come into the world we know not, but ’tis commonly no easy matter to get out of it.

—Sir Thomas Browne,

Religio Medici

I wasn’t the first to arrive in her room. The resident had already started the code, and nurses, physicians, and medical students crowded around her bed,
performing CPR. The patient, a woman in her sixties, bore the physical scars of many life-saving interventions for deadly issues ranging from heart attacks to strokes to blood clots in her lungs. Six different IV bags with
medications hung on poles on either side of her bed. A tube stuck out from her neck and was connected to a breathing machine. Otolaryngologists (specialists in conditions of the nose, ear, and throat) created a tracheotomy for her months ago, cutting an opening through her neck because she
could not breathe properly through her mouth.

This was all I knew when I walked up to her bed, where ten physicians and nurses ran through the protocol necessary for restarting the patient’s heart. In
addition to defibrillation to
shock the heart back into rhythm, physicians give epinephrine to augment the effects of CPR.
Epinephrine raises blood pressure by constricting blood vessels, thus increasing the flow of blood into the brain and the heart. And, it binds to beta-1
receptors in the heart, improving the heart’s ability to contract.

A well-run protocol, or code, has a rhythm: Epinephrine is given every 3 to 5 minutes, chest compressions are performed thirty times for every two breaths, the heart is
shocked at the stop of compressions, and then we start over from the beginning. If there is a competent leader, then despite the chaos of human bodies crowding around the spectacle of death, opening drawers for medications, and
thumping on the patient’s chest, there is still order, a pattern, a method, a purpose.

Wikimedia Commons

When the resident doing chest compressions tired out, she shoved me to take her place the next time around. Chest compressions are intense, both
emotionally and physically, and one tires easily. So we cycle in and out — we compress for as long as our bodies allow and then make way for a colleague
who is next in line. I stepped up and began my compressions. The compressor must replicate the beat of the patient’s heart. If you go too fast, the heart
does not have time to fill and you don’t pump blood to the brain; too slow, and the brain is deprived of oxygen and your compressions are useless.

The patient’s eyes looked up at me as I pounded my palms onto her sternum rhythmically and her whole body shook. Still open, a thin glassy film covered her eyes, clouding the stuff of life that normally emanates from a human’s gaze. Feeling uneasy as the object of her empty stare, I looked up at the
TV: two pop singers were apparently at war on Twitter.

At some point — I can’t remember how early or late in the process this occurred — the patient seemed to gasp for air. She growled and gurgled, desperately
reaching for the elemental gas which we take for granted every time we inhale. This may have been her agonal breathing, a process that some experience on their way to death. The late Dr. Sherwin Nuland, a surgeon and writer, described this in his book How We Die: “The adjective agonal is used by clinicians
to describe the visible events that take place when life is in the act of extricating itself from protoplasm too compromised to sustain it any longer.” He
continues,

The apparent struggles of the agonal moments are like some violent outburst of protest arising deep in the primitive unconscious, raging against the
too-hasty departure of the spirit; no matter its preparation by even months of antecedent illness, the body often seems reluctant to agree to the divorce.
In the ultimate agonal moments, the rapid onset of final oblivion is accompanied by the cessation of breathing or by a short series of great heaving
gasps…. (p. 122)

 
Indeed, this is what the patient seemed to be experiencing. But was it? One resident tore open a drawer, found a thin, long, hollow tube and connected it
to the suction machine on the wall. Perhaps, he theorized, the patient had a mucus plug in her airway. In patients with tracheotomies,

the air bypasses the mouth which normally cleans and moistens the air we breathe
. In response, the patient’s body produces more mucus, which accumulates and blocks the flow of oxygen into the lungs. This could be an easily reversible
cause of the patient’s sudden deterioration.

The resident pushed the suctioning tube into the patient’s trachea while a nurse called the otolaryngologists who had placed the tracheotomy and were
better trained to deal with it. The resident retrieved small bits of mucus out of the patient’s airway, but we still needed to continue CPR. Eventually,
after many attempts to revive the patient, the attending physician looked at the clock and, realizing it had been 25 minutes since the code started, asked:
“Does anyone have any other ideas as to how we can save this patient?” Met with silence, he nearly declared the time of death to be 3:32 in the afternoon.
But the otolaryngologist shouted that he had finally gotten something. A long, viscous, and yellow-brown piece of mucus shot up into the suction tube and
the patient gasped for air. Her heart began to beat appropriately again; her respirations normalized. Within five minutes she was back to her old self
again, sick, yet alive and aware, conversant via hand motions and mouthing of words. She could now let us know that she existed. The glassy film retreated
from her eyes as she was pulled back from death.

This is an uncommon circumstance. In

a study in The New England Journal of Medicine in 2009
, researchers studied Medicare patients 65 years of age or older who underwent CPR in U.S. hospitals from 1992 through 2005. They found that only 18.3 percent of
these patients survived to discharge. Over the course of this time “the proportion of in-hospital deaths preceded by CPR increased, whereas the proportion
of survivors discharged home after undergoing CPR decreased.” It seems that CPR has not gotten better, and the authors express “significant concern” that CPR has increased “during a time of more education and awareness about the limits of CPR in patients with advanced chronic illness and
life-threatening acute disease,” like the patient we revived.

And yet, who can argue with the results that day? I wrote in my last post on CPR that “we rightfully value human life above all
else and thus owe the patient every weapon in this battle. While the rapidity of the process may seem callous, it is essential in a last-ditch effort to
stave off eternal rest. After all, what if she had been revived?” In this patient’s case she was fortunate. Yes, she was still critically ill, but perhaps
this gave her more time to be with her husband, who had been visiting her for months. Maybe now she could have the conversations with her family about
whether she wanted CPR done in the future if her condition worsened (she and her husband eventually decided they didn’t want any further CPR measures — this
one experience was traumatic enough). Alternatively, perhaps this revival would change nothing about how she would use her time on this earth. It is not for
physicians to say how she ought to use her new-found days; it is only for physicians, when appropriate, to help her grasp them.

Death and ‘The Death of Ivan Ilyich’

There is much in Leo Tolstoy’s frightening and brilliant story The Death of Ivan Ilyich that is relevant to my previous post about CPR in the hospital. The novella concerns an upper-middle-class judge, Ivan Ilyich, his rise within the Russian legal system, and his subsequent death. Tolstoy describes Ilyich’s unremarkable and vapid professional and personal life — his accomplishments are not long-lasting and he despises his wife and cares little for his family — and contrasts this profoundly with Ilyich’s lingering march toward death.

I’d like to focus on two of the interesting points that Tolstoy makes about death. First, death itself is only a concern for the dying, while others are insouciant, opportunistic, or burdened by the obligation of dealing with a friend’s passing. Upon hearing of his death, Ilyich’s legal colleagues first thought “of the changes and promotions it might occasion among themselves or their acquaintances.” And one friend complains about traveling to the funeral: “…but they live so terribly far away.” Perhaps even more disturbing, “the mere fact of the death of a near acquaintance aroused, as usual, in all who heard of it the complacent feeling that, ‘it is he who is dead and not I.’ Each one thought or felt, ‘Well, he’s dead but I’m alive!’” Again, Tolstoy emphasizes the disturbing frustrations Ivan’s friends felt: “But the more intimate of Ivan Ilyich’s acquaintances, his so-called friends, could not help thinking also that they would now have to fulfill the very tiresome demands of propriety by attending the funeral service and paying a visit of condolence to the widow.” This haunting view of human nature should make us all cringe — how lonely death is and how cruel is the human response to it!

On that night I helped perform CPR, were those of us surrounding the dying patient in the hospital feeling as insouciant or feeling as burdened as Ilyich’s friends? Though Tolstoy’s dark view on such matters may hold true in some cases, I think that experience on the night shift was completely antithetical to Tolstoy’s understanding. In the hospital room, the feeling was not one of an obligation or burden. The attending physician kept CPR going because he wanted to give this young woman every shot at coming back to life. Then, he hurriedly tried to get in touch with the patient’s family, trying cellular numbers, home numbers, and even work numbers, to tell them what had happened. He covered up her chest with a blanket out of respect for her. And when he called the time of death, the palpable silence in the room was telling. There were no words to account for this process. In some ways, silence was the appropriate response. Nobody complained about other chores they had to do, or about the paperwork that had to be done or how much time they spent trying to resuscitate this patient.

Tolstoy also writes about the experience of dying, which makes up a large part of the novella. Ilyich sees death on the horizon and his inexorable march towards it. “In the depth of his heart he knew he was dying, but not only was he not accustomed to the thought, he simply did not and could not grasp it.” Ilyich attempts desperately to ignore death: “The pain did not grow less, but Ivan Ilyich made efforts to force himself to think he was better.” Towards the end of this process, Tolstoy describes Ilyich’s reactions: “[He] wept like a child. He wept on account of his helplessness, his terrible loneliness, the cruelty of man, the cruelty of God, and the absence of God. ‘Why hast Thou done all this? Why hast Thou brought me here? Why, why dost Thou torment me so terribly?’ He did not expect an answer and yet wept because there was no answer and could be none.” This is compounded further by Ilyich’s regrets about the life he led: “And the further he departed from childhood and the nearer he came to the present the more worthless and doubtful were the joys.” These moving passages summarize the dreadfulness of Ilyich’s confrontation as Tolstoy drags the reader through this horrific scene. During the last few days, Ilyich screams continuously, which is “so terrible that one could not hear it through two closed doors without horror.” And it is only when Ilyich admits to himself that his family would be better off with him dead (“It will be better for them when I die”) instead of watching him die, that he is freed from his pain and “in place of death there was light.”

Interestingly, Ilyich initially approaches his final minutes the way those who do CPR approach death, the way Dylan Thomas wanted his father to approach death, and the way so many people encouraged Christopher Hitchens to approach his cancer — with rage and a desire to do battle. Ilyich clings to false hope and attempts to confront death. In the end, though, he mitigates his suffering and the suffering of others only by submitting peacefully to his inevitable passing. Does this mean one must always allow death its victory, and must even pursue death, through means like euthanasia, when one is in intense pain? No, I think Tolstoy’s point is far more nuanced than that. Ilyich does not commit a form of suicide; he merely accepts his fate, which is when his pain and fear disperse. A good analogy might be the kind of care the field of medicine provides to terminally ill patients. We now attempt to provide comfort and care for the dying through hospices, institutions which give nursing care and pain medications to those with terminal illnesses in order to make their passing a comfortable rather than a painful struggle. This method is increasingly common and improves patients’ quality of life at the end in certain instances. (I will write more about hospices and issues related to end-of-life care in coming posts.) And this does not invalidate the option for a fight when it is appropriate and when something can and ought to be done. For those other than Ivan Ilyich, like the woman in the hospital on that night, there is still the hope of being saved. This option we must pursue no matter how difficult the pursuit is, so that, to borrow from Tolstoy, in place of death there is life.

CPR in the Hospital

Can storied urn or animated bust
Back to its mansion call the fleeting breath?
Can Honour’s voice provoke the silent dust,
Or Flattery soothe the dull cold ear of Death?
     — Thomas Gray, “Elegy Written In a Country Churchyard

The graveyard shift, or overnight shift, in the hospital is a singular experience — quietude envelops the bare hallways. Phones and pagers echoing throughout the day go (mostly) silent; social workers or teams of residents and medical students do not round from patient room to patient room; and there are no visitors carrying food from the cafeteria to their ailing loved ones. It almost seems as if human sickness has been put on hold, as if each patient’s cells just paused overnight in order to sleep and resume activity again the following day. This false sense of peace deceives newly minted third-year medical students. Just because human beings evolved to sleep at night does not mean the pathology of disease stops. No, a cancer cell cares little about the time of day and viruses disregard our circadian rhythm. And that’s why there is the night shift — that’s why medicine must never sleep. Sometimes, it takes dramatic events to remind one of this.

I remember the eerie robotic voice over the hospital loudspeaker: “code blue, code blue.” In hospital lingo, a “code” is an alert in a hospital, and “code blue” is a common indication that a patient in the hospital is dying and needs help immediately. Physicians, nurses, or other healthcare workers trained in CPR (Cardiopulmonary Resuscitation, used to revive a patient whose heart has stopped) rush to the room to help the patient. When a code is called, everyone knows his or her role. A code leader directs the administration of medications (usually epinephrine to help increase cardiac activity); a respiratory therapist manages the airway, making sure that air is flowing into and out of the lungs; a nurse ensures good intravenous (IV) access in the patient’s arms for the administration of drugs into the blood; and another team member compresses the patient’s chest to force the heart to pump blood throughout the body.

That night, a patient with a terrible history of visits to the intensive care unit due to infections and disease had gone into cardiac arrest. And as the two third-year medical students on our night shift, one of my classmates and I were coincidentally on the same floor as the patient. Several physicians and nurses were already by the patient’s side when we got there. A nurse ushered us into the small room to perform chest compressions on the deceased woman (medical students assist the code team in fulfilling whatever role they assign us). We edged into the room, approximately 8’x11′, trying not to bump into the hospital staff. The massive “code cart” lay by the foot of the bed, its drawers half open with torn bags, empty boxes, and medication vials which were used when the code began. There were eight or nine other people in the room, as well as the patient. She was lying face-up on the bed, half covered in a hospital gown, breasts revealed, an oxygen mask over her face to help move air into and out of her non-autonomous lungs, head tilted to the side, eyes blankly staring beyond the wall of the room. I didn’t know what to do or how to react, but there was no time for being pensive as we rushed to the side of the bed.

We began chest compressions. The technique is straightforward: put one hand over the other, stand almost directly over the patient’s chest, and “push hard, push fast, and allow for good chest recoil” according to protocol. This replicates the rhythmic beating of the functional heart and allows for it to fill with blood as the chest expands much like a sponge soaking up water after being released. The heart, however, is protected by some of the chest bones (rib cage and sternum). And CPR is no gentle process. Upon pushing down, one feels the ribs being so forcefully compressed that they crack, a common manifestation of this physical maneuver.

As we compressed, this poor woman would bounce up and down in the bed because of the force. We took turns compressing when we became too exhausted to continue. Meanwhile, the respiratory therapist pushed oxygen into the woman’s lungs through the mask, the nurses administered epinephrine via the IV every three to five minutes, and the others looked on in silence. Nobody said a word for the entire time this went on unless it pertained to how much medication to give the patient or when to administer a shock with the defibrillator. Occasionally, we ceased compressing and felt for a pulse but each time there was no rhythmic beating of the blood in her arteries. Despite the team’s efforts, more and more of the patient’s cells swelled and burst due to lack of oxygen; one after the other; millions upon millions irreversibly perishing.

Eventually, after determining that no strand of hope remained, the physician called the patient’s time of death. As quickly as CPR had begun, it also concluded. We stopped compressing. The respiratory therapist removed the oxygen mask and shut off the oxygen tank. The nurses packed up the code cart. The physician covered up the woman’s chest with a blanket. The medical team dispersed into the desolate hallways to care for other patients, leaving the nurses on the hospital floor to make arrangements for the patient’s body. As participants in the evening’s tragedy, we left to wander the halls and somehow come to terms with the suddenness of what happened and what we had just done.

Thinking back on that disquieting evening, I am reminded of the famous and oft-quoted poem that Dylan Thomas wrote in preparation for his father’s death — “Do Not Go Gentle into That Good Night.” The wonderful audio recording of Thomas reading the poem is here and you can read the text here:

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.

Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.

Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.

Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.

And you, my father, there on the sad height,
Curse, bless, me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.

Thomas pleads with the dying to take arms against death that comes too soon. And this is how we think about issues like death and disease. The late Christopher Hitchens, while being treated for cancer, observed, “those other glorious ‘wars,’ on poverty and drugs and terror, combine to mock such rhetoric, and, as often as I am encouraged to ‘battle’ my own tumor, I can’t shake the feeling that it is the cancer that is making war on me.” The metaphor of a war against cancer or a war against death is misplaced. We have less control than we wish. We are at the mercy of the virulence of a disease, the sequence of our genome, or the power of modern medicine, not always of our own strength or desire to live. Moreover, the dead and dying do not rage or fight. Our dying patient that night probably felt, for an instant, the inability to breathe, an intense pain in her chest, a drastically elevated heart rate — and then, immediately after, nothing.

We, the living, fight death on behalf of the dead. We take up Thomas’s plea. We compress chests, we pump air, we deliver electric shocks and medications to try to restart the patient’s heart. We did not let her go gently into that good night. We fought her fight as if it were our own. But the sheer humiliation and vulnerability of the patient during this event makes one question how much of this battle should be fought. How much do we honor this person’s memory by pounding on her chest as she lies half naked in a room filled to capacity with strangers? Yes, it seems cruel. And yet, we rightfully value human life above all else and thus owe the patient every weapon in this battle. While the rapidity of the process may seem callous, it is essential in a last-ditch effort to stave off eternal rest. After all, what if she had been revived?