Day 538: Good Cop. Bad Cop

I still remember when I visited a program for a residency interview and one of the invited interviewers asked the program director- "In all your years here as program director, what makes a good resident? who were your most memorable residents, and why were they special? What made them stand out amongst the rest?" He stood quiet for a few seconds and then responded by saying "I have been program director almost 20 years, and when I look back at all the residents I have ever had, the really great residents where the ones that truly cared about their patients. They always where asking why things were happening and were always trying to find a solution. Their were many times I asked residents what certain things were happening in their patients, and many of them never bothered finding answers or maybe never really cared that much."

At the time I never really could appreciate or understand these words, but I did yesterday. We had a patient that was admitted to the unit for abdominal pain and had developed a doudenal perforation, and she then became septic and had DIC (disseminated Intravascular coagulation). She had been placed on pressors for her hyotension and was getting antibiotics and frequent platelet and blood tranfusions for her condition. I also believe that she coded one time. On of these special residents had been involved on her care the entire time at her stay in the unit. She had been working vigorously with her for almost 2 weeks. The code status had not been fully adjusted and there was no agreement because the POA was a 21 year old nephew. So whether or not they should have gone as far as they did, could have been debated. The patient yesterday seem to be in her final stages of battle with sepsis. She had been on levophed and "maxed" out (according to the ICU attending, there really is no max on levophed you can go higher with the doctors approval.)The fact that they went higher on the levophed also caused more vaso-constriction on her hands and feet, and she had been developing gangrene on her hands and feet. In the morning the intensivess had passed by to see her progress, and he was told that her direct billirubin had been going up to 20 (it was believed that maybe it was caused by the tpn, so it was stopped.) They had done a hida scan and had showed that the bile duct was being obstructed. GI had seen her and did not suggest any surgery or further testing at the time except a liver ct. The intensive said that I think its time to let her go. Within the next 3o minutes he called the family to give them the bad news. The resident that had been working trying to keep her alive also tried to contact the family. The family was not yet fully responsive and wanted a few more hours to think about it. In the afternoon the family had passed by and as I walked into the unit around 4:30pm this senior resident told me "I made her comfort measure."

I turned to her and said "you did the right thing." She only smiled and started walking to visit the patient room again.

I stood around till 5pm because I needed sign out, and I was on call. She then told me "I'm going to go into room and I'm going to do the terminal extubation." The family members came out of the room, and she went into the room with 1 nurse and the respiratory tech. It took about 10 minutes when she finally came out of the room. She turn to me and said "I did it."

She then walked over to the vital signs monitor to check on the vitals signs of the patient she just terminally extubated. It was amazing to see that within 1-2 minutes her heart rate when slowly down. 80...70...60....50...20...0. Then next to go was her heart monitor. Slowly it flat lined. I stood their quietly observing her reaction. She stood their staring at the monitor quiet with her hands folded and one arm over her mouth. She seem to be thinking about the moment. She turned around and started walking back to the resident room. I met her half way and told her "you know... you did everything you could. She was lucky to have you as her doctor. You did the best anyone could. She couldn't have lived longer with nay resident, but you." She looked at me and stared down at the floor. I think she wanted to cry but she felt shy. I put my hand around her shoulders and gave her a short hug. She sign off the other patients she had in the unit, and I told her "you can go home now."

As I walked out of the resident room thinking about all that had happened and as I was about to walk out of the unit, I turned around to look back at the patient room. I could see this resident going back into the room and I could hear her tell the nurse "we can get them the funeral numbers if you need them. Let me help you."

It was passed 5 pm and she was signed off duty. But I know she was staying longer, and she did...

On my way driving home I thought about what I had just seen. I was glad that I was their to witness what I had seen. It was good to see someone who cared. Someone who had fought for someone else. She had earnestly tried everything she could and you could see. It is good too see "bad" and "good" physicians. Its good to see people who care and don;t care. You learn what you shouldn't be and what you should be.

Looking back on what I had experienced, I knew that I would always have a clear picture in my mind off what makes one doctor stand out above the rest; about what makes a human being a special one. It is healthy to have good passions, it is even better to have passions directed towards helping others. It is not really what you know, but how much you are willing to help someone. Even with limited knowledge, someone who is fighting for the life of someone, will find answers.

God Bless.

Dr.Mike