Thursday, June 16, 2016

Christmas 2015 - part 1.

I have decided to begin a new initiative in my life to improve my writing. Or, more accurately to improve the volume of my writing. Whether this will make any change in the quality of my writing remains to be seen.

I don’t post to my blog often because I tend to write only when I feel I have something to say. However, often times when I feel words coming forth and begin composing lines in my head I am not sitting near a computer or pen and paper so those words are lost and along with them an important piece of me. That’s not to say that I am walking around with little thoughts flying out of my head left and right as I just shrink smaller and smaller and slowly disappear. I think their loss affects me only. As they disappear, I lose touch with my thoughts and my feelings and it becomes harder to express myself simply because I am out of practice.

So, thus begins the new plan to write for 30 minutes per day, regardless. Timer set, words out. I am not going to edit. I am going to try not to edit. The goal here is to simply put thoughts on paper (well, simply put thoughts out of my head) and not produced some finished piece.

Yesterday, I had an interesting idea for a book. I want to compile a bunch of short stories from intern year. Writing the whole year as a narrative would be terribly boring for anyone to read. (Countless hours of note writing, article reading and crying to sleep). But there are a few instances where time slowed down and the stories etched themselves on my mind. The baby that was born Christmas morning shortly after I arrived for what I anticipated would be a quiet day in the NICU – that terrifying sensation of running into a room where CPR is being done on the still pregnant mother and realizing that two lives literally hang in the balance.

On TV, the codes run smoothly, there is some yelling and arguing for dramatic effect, but what you don’t see is the realistic crowd of people. In the hospital, codes are commotion. They are paged via the overhead paging system and the rule is that someone from every department has to go. Not someone – a doctor. That is because when a heart is stopped, every second matters. And when it happens – it happens anywhere. Who knows who will reach them first? That’s why the best bet is to have someone running from every direction. Because no matter what someone will be there in moments.

The problem with this is that once the page is sent, there is no page revoking system. So once the first person arrives on the scene, the second person usually arrives seconds later. Then the third, then the fourth, then the fifth, then the sixth. All this help is fantastic at first – one person does CPR, one person manages the patient’s airway (gives breaths with a bag and mask or puts a tube in the patients throat if necessary) another person is responsible for medications – drawing up the correct dose and administering it when called for (this same person also usually starts an IV and gives IV fluids), another person is responsible for writing down everything that happens. Hospitals have special paper forms for this with the usual medications listed and a basic structure outlined. More often than not, these rough timelines are scribbled onto the back of whatever the person has in their pocket or nearby. It could be a patient list from a completely different day, it may be the notebook they have been using to record lab values, and sometimes its just paper towels pulled from the dispenser.

Another person is responsible for “running the code”. They do none of the above functions, but rather stand back and observe the whole scene and direct, similar to leading an orchestra. It doesn’t matter if you are a fantastic bassoon player and the bassoons are doing a terrible job… if you step off of that podium to take over for them, the whole thing will become unraveled rather quickly.

So, in a perfect world, a code with approximately 6-7 people is ideal. Everyone has their roles and stays in their lane while simultaneously helping the person in charge look for things they may have missed.

When a real code happens, there is usually 20-30 people in the room. 20-30 well intentioned people who have been trained to save lives. People who know that the patient currently in the eye of the hurricane is in dire need of help. People who have chosen their career path because they want to help.

In real life, you may have 6-7 people performing their roles perfectly, but you also have about twenty onlookers, with all the best intentions, valuable expertise and relevant training who, quite frankly, are just in the way.

The average person not in the healthcare field has no reason to see that scene generally unless it involves them personally or a loved one. I assume in those instances, they are fairly distracted from the crowd of faces present.

Initially, my idea was to tell multiple stories like that one. (Well, that really wasn’t the story… I guess just a long set up to explain why I felt the story needed to be told).

I told this idea to a dear, dear friend of mine who expressed encouragement and then unexpectedly shared her own version of the same story. I had forgotten she had been there that day as well, on a different floor, uninvolved in any of the previous care of the patient… and then she got the page, and, as expected, took off running, realizing on the way that her day had just completely changed course.

When I walked (ran) into the OR in the labor and delivery unit, I knew already that this baby was not going to have a long life. It had been diagnosed prenatally with a genetic condition that would support life for a year at most, but even that long was unlikely. I knew the mom was at full term, baby was appropriately sized, it was her first baby and apart from the known condition of the baby, she had previously had a healthy pregnancy. All that said, I had all sorts of reasons to be reassured that this mom was going to be okay and also a general feeling of foreboding that baby was not while at the same time feeling (terrible as it may sound) relief. Relief that this was not my fault, that even if I gave this child my 100% best effort and all the medicine and work and life-saving efforts… it was not going to die because I had failed.

Emotions tend to take a backseat walking into a code scenario. The only thing to feel at that point is adrenaline and instinct. That is why we practice, why it is drilled into us as medical students, doctors, nurses, respiratory therapists… A. B. C. Airway, breathing, circulation. If you can only think of one thing, you know where to prioritize and simply let instinct take over.

When I arrived in the OR, the pregnant mother was on the operating table – unmoving. A teenaged enlisted sailor in the navy was doing chest compressions. OB-GYN nurses were at the bedside in a cluster. Someone was yelling into the hallway “Call a code blue! Call a code blue!”. An anesthesia resident – clearly designated by his blue scrubs was at the head of the bed, drawing up meds. The staff anesthesiologist appeared only seconds later.

The code blue was paged. Within seconds, 40 people were in the room –OB-GYN providers in their cranberry scrubs. Pediatrics in their cranberry scrub bottoms, festive shirts and Christmas headbands. Anesthesia from multiple units with blue scrubs and colorful scrub hats. Other specialty providers in the uniform of the hospital – dark green scrubs, and the occasional civilian nurse with fancy patterned scrubs that are only really noticed in a hospital where everyone else is required to wear the same thing.

When I walked in… it was chaos. Despite my background knowledge of the patient, the reassurances that mom was previously young and healthy and fully expected to have a normal delivery, I was overwhelmed.

Dr. C. My friend scheduled on the pediatrics floor that day, walked (ran) into the same scene, but from an entirely different vantage point. Her responsibility for the day was to the patients three floors below. The patients whose charts she had spent the morning reading and learning.

It was hearing her story that triggered a new idea in me. For all of the stories of intern year that have stuck with me (except for one terrifying scenario involving a limp, blue baby) there have been other doctors involved – from various specialties and at various training levels. It would be interesting (to me anyways) to compile short stories, but from multiple vantage points. The pediatric intern (me) in way over her head. The pediatric upper-level resident familiar with code scenarios but with no knowledge of this particular patient. The upper-level anesthesia resident who came running from a different floor in response to the code blue. The teenaged medic responsible for the chest compressions. Another pediatric intern was not present for the code, but was there with the family when later that night, the baby passed away.

These moments, they affect us. Even if we have seen them all before and will see them all again. It’s hard to explain to people who haven’t been in that scenario. My parents, visiting for Christmas, came to the hospital to have lunch with me. I barely was able to sneak away as we were still trying to stabilize the baby, 5 hours later. When I told them the story of my morning, explained my tardiness to meeting them for lunch, my mom had only one question. “Is the baby going to die?”

“Yes. Honestly, I am surprised she hasn’t already.” We had explained to the family it was fruitless. The child was terminal regardless and x-rays from shortly after birth demonstrated minimal lung tissue. Whatever they had been promised regarding taking their child home, we were not going to be able to give to them.

At that point, I was frustrated with the family, because despite all the information we could give them about their child’s prognosis and timeline, they wanted all possible life-saving measures taken. (For non-medical people, that means we are keeping this baby alive no matter what. There was already a tube in the baby’s throat with the machine breathing for her, but if her heart were to stop, we would begin chest compressions and do everything we could to bring her back.)

We had other sick babies in our NICU. Non-terminal babies that also needed our time and attention. It all goes back to medical ethics and resource allocation and how do I justify spending hours trying to save this baby that is definitely going to die and ignoring this baby that is sick but will likely live?.

I tried to explain this to my mom, who was a bit taken aback with my non-chalant answer. “Put yourself in their shoes” she begged “would you want to just let your child die?”.

What she didn’t understand was that I had thought of that, and that I couldn’t now. I can’t imagine that baby is mine right now because I need to know what that baby’s lab values show, and how fast her heart is beating and the settings on her ventilator. I need to know about the 8 other babies I am responsible for – what is their blood sugar, how much have they urinated today, does their white blood cell count indicate an infection, is their chest x-ray getting worse?.

What I couldn’t make my family understand is that my heart was breaking too. Separately, silently, because I had to go back to work. I had to talk to the baby’s father, a non-medical 19 year old. I watched his face as yet another doctor told him his daughter was going to die. I noticed he had on athletic sandals with socks. He had a lanyard hanging out of his pocket. Apart from the OR hat he had forgotten to remove, he could be an average high-school student heading up to the basketball court to shoot some hoops.

He was so young. His face indicated no understanding. His daughter, just recently born and yet barely alive only three feet away. His wife, downstairs in the intensive care unit, still unconscious and not breathing on her own. I was older than him. Yet I had nothing that I could even come close to relating to his life experience at that point. I wanted to hug him and cry for him and at the same time I wanted him to leave, because I had work to do.

So I guess that’s the goal in telling my story and the stories of others. I don’t have the skill to succinctly explain everything. I can’t make you understand what I feel without walking you through these moments that I will never forget. Even when I’ve been through millions more just like them.

This baby was born around 7:30 AM. We spent all morning fighting to keep this baby alive, trying to manage the other patients, worrying about the state of the mother, and of the other physicians in the room. Talking to the new father and grandmother. Fielding questions from nurses. Examining other babies. Attending other deliveries – these with healthy babies and happy families with their Christmas miracles. Trying not to resent them and feeling as though their happiness was almost offensive, in light of everything that had happened, but instead cooing over the new baby saying for the millionth time how he was absolutely beautiful. A healthy baby boy. 7lbs 5 oz. Perfect size. Normal. You should get to take him home in only a few days. Congratulations. Then, I was eating lunch with my family, trying to explain how my day was going. Trying to be pleasant because it was Christmas, after all.

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