Friday, March 28, 2014

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.

Wednesday, March 26, 2014

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?

Monday, March 24, 2014

Residents and Rounds

Doctors practice “grand rounds,” ca. 1920s.
(National Library of Medicine)
This post is meant to provide a bit of background about how the day works and how a medical team functions so the references I make in future posts are clear. Let’s begin with the team. Nearly every medical team at an academic hospital consists of an attending physician, residents, interns, and medical school students. While these terms might sound familiar to anyone who has watched medical dramas on TV, it’s likely that most people don’t know what they mean. The attending physician is a bit like a tenured professor. He or she has the most experience and training in the operating room and the clinic, and has graduated from medical school, residency, and, in most cases, a fellowship program.

The residents, having graduated from medical school, are also physicians but, being less experienced, are “attendings-in-training,” learning the craft of a specialty via instruction from an attending physician. Residents are classified by the number of years they’ve spent in training, and different specialties will require a shorter or longer residency: there are chief residents (the most experienced residents), fourth-year residents, third-year residents, and so forth. Then there are the interns, physicians who have just finished medical school and are spending their first year out of school rotating through different specialties, learning how to enter orders for medications, writing progress notes on patient care and discharge notes to release patients from the hospital, and responding to immediate issues that arise during the course of the day. To do this an intern must know each patient in order to respond to questions about treatment from the patient and nurses.

Third-year medical students comprise the lowest rung of this ladder. We have little to contribute and plenty to learn. Frequently, we are assigned to follow a few patients and come to know as much as we possibly can about them. Once we know everything about our patients, it will be easier for us to think about what is most important regarding each patient’s care. We learn to pay attention to important details.

This team hierarchy, though it may seem stilted, is actually integral to the process of rounds, where the medical team visits each patient in its care. Rounding provides an opportunity for the healthcare team to speak with patients about how they are doing, to look at and physically examine them. The physical part of the exam is fundamental to healthcare. The abdomen, for example, can feel distended or stiff if there is a certain pathological problem, such as a bowel obstruction. Only by palpating — touching the patient’s body — can we know this. One cannot assess a patient’s progress until one examines a patient.

There are two official times to round during the day. One is immediately upon arrival at the hospital without the attending physician. This involves residents and medical students. And the other is with the attending physician later in the morning. While shuffling between different floors and patients, the hierarchy remains eminently clear. The attending physician leads the charge and behind him or her follows, in order of experience, everyone else: the third-year, the second-year, then the interns, then the medical students. There are usually about eight of us rounding together; to an untrained observer, we might look like the motorcade of a foreign diplomat. We all squeeze into each patient’s hospital room as the attending physician conducts the interview with the patient, assesses the patient, and tells the patient what the team’s plan is over the course of the day: Will a new medication be prescribed? Will the patient finally be able to eat food? Can the patient only drink liquids? As the attending explains this to the patient, one of the interns runs over to the computer inside the patient’s room and enters in the new medication orders or dietary orders. And on to the next patient. Over the course of the day, the new orders are confirmed and reconfirmed with the attending and upper level residents,

This daily pattern of rounding is actually a tradition as old as the American hospital system itself. In earlier days, there was a system of apprenticeship. So, if you wanted to be a physician in late-eighteenth-century America, you would be apprenticed to a doctor who would teach you all that you needed to know. You would then probably be offered a partnership with your teacher. But as the hospital and medical school system took root in the early nineteenth century, students pursued learning opportunities in hospitals in order to receive a more thorough practical education en masse. Individual physicians, after all, had very little time to apprentice aspiring doctors, and frequently the knowledge you received depended solely on one person. In order to teach medicine, hospitals created special programs where students would, as they do today, pay a fee for a basic science education (meaning anatomy, physiology, and pathology) and, eventually, a clinical one as well. Students rounded with residents (also known as house staff) and attendings in order to receive this practical experience in patient care. One description of rounds in Massachusetts General Hospital by Dr. James C. White in the 1850s sounds eerily familiar to me:

[The attending physicians] pass from bed to bed in the large wards, the students following. The house [officer] narrates any incidents in each patient’s condition during the previous twenty-four hours; the physician asks questions, makes the necessary explanations, and directs treatment. Over new and interesting questions much time is spent.... Students have nothing to do with the investigation of cases; they have only to look and listen.

My theory about this process as an educational tool is that it is suited to the role of each member of the team. The upper-level resident should be learning how to dictate orders and take charge of the team because soon he or she will be in that position. The attending, who knows this process well, educates the upper-level resident on whether the plan of care is correct and guides the fourth-year or chief resident. The mid-level resident follows closely on the heels of the upper level because he or she will soon occupy that position. And the interns need to learn how to manage patient care on a detailed level, writing notes and orders to improve at compounding a ton of information into a paragraph or two and assessing doses and units of medications.

And we, the medical students, observe and listen and ask questions when we can. Our purpose is to learn the language by observing patterns in patient care and disease. Thus far, it’s difficult to tell whether this strategy is working; it sometimes feels like I am back in French class on the very first day, listening to a language I’ve never heard before regarding dosages, plans of care, boluses, IV infusion rates, and so forth. But it is also comforting to know that this process has worked for more than a century and a half, and so perhaps we third-year medical students are right where we should be.

Why this blog?

In Robert Louis Stevenson’s The Strange Case of Dr. Jekyll and Mr. HydeDr. Jekyll says, “when I reached years of reflection, and began to look round me, and take stock of my progress and position in the world, I stood already committed to a profound duplicity of life.”

It is appropriate that Stevenson chose a physician as his protagonist who is tortured by that duplicity, because doctors regularly experience the opposition between their own training, which uses reason to make logical sense of intricate systems, and the apparently disorganized nature of malfunction, dysfunction, and illness. This opposition comes to the fore when we as patients must reveal to our doctors the private history of our families, our surgeries, our secret habits, our likes, our dislikes, our tenebrous deeds — all for the purpose of helping our doctors make ordered sense of our often disordered selves.

One of the very first lessons a medical student learns is that of eliciting a thorough history from a patient, a history that can clue the physician in to what might be going on. The aphorism “Listen to your patient, he is telling you the diagnosis,” or some version of it, is commonly attributed to Dr. William Osler, one of the great physicians of the late 1800s and a grandfather of modern medicine. How can a physician diagnose a patient with a sexually transmitted disease without knowing about a patient’s sexual history? A patient reveals secrets to a physician in the hope that this might help the physician in his diagnosis and treatment.

While we learn this fact during the first two years of medical school, the actual work of those two years is to cultivate a rational detachment from medical practice. The major task is to memorize as much information as possible about physiology, pharmacology, biochemistry, pathology, and anatomy — to immerse oneself so thoroughly in this new and strange language that it becomes second nature. The first big standardized exam, called STEP 1, covers these basic sciences and must be passed by every aspiring physician in the country. It is the gateway between a life based on books and pure mental work and the practical work of the third year, where I am now. During this third year, medical students spend about a month or more in each general specialty area: surgery, pediatrics, psychiatry, neurology, internal medicine, emergency medicine, obstetrics and gynecology, and family medicine.

During each month, we are considered a part of a medical team on that “service.” We interview, assess and help treat patients; we sit in on conferences, draw blood, and start intravenous lines to deliver drugs into the body. We begin to speak the language of medicine. We see what doctors see but we see it for the very first time. Like a child discovering the ability to walk and speak, a third-year medical student discovers how to live and breathe the complexities and uncertainties of a life in medicine.

This privilege elicits all kinds of reactions as death and life, sickness and health, are laid bare before us. We straddle the line between the physician and the patient, between the rationalist and the sufferer. The only side we have known until this point is the latter, but we are quickly initiated into the former. We stand committed to the profound duplicity of life. This singular position, which we don’t occupy for too long, as the novelty begins to fade, provides an opportunity to see with eyes still fresh a world that for many outsiders is shrouded and hopelessly complex, with a confusing array of specialties and subspecialties accessible only by the expert. Inevitably, in one way or another, all of us participate in this drama, whose plot centers on the relationship between physician and patient. In this blog, I hope to shed some light on my introduction to the inner workings of the medical field — and in doing so to illuminate some of its theoretical, practical, and ethical complexities.