on death and dying.

Well, first I'd like to start out with a link: http://www.youtube.com/user/rockyandballs#p/u/0/WO1QM2rH3KE

Today was another bang-up day on neuro. Consult #1 was a gentleman in the ICU who had already been in the hospital for 6 days. We were consulted for recurrent altered mental status. At the moment, however, his mental status has resolved. So .... there is nothing but a normal guy to evaluate.

*break* for some excellent noon didactics including a great trauma resuscitation lecture and a delightful M&M

Return in the afternoon for a consult on a lady in the ED who has aphasia, gaze preference, R sided paralysis, R facial weakness & decreased sensation. Fuck. Only thing - it started yesterday, in Florida, at 7:30pm, when their flight was on the tarmac. Then - dude brings his wife to a hotel and thinks she's just tired and *finally* brings her to the ED @ about noon today. During the exam, his biggest concern is how he's going to get his luggage which is on its way to San Diego. Let alone that his wife has a massive L MCA stroke (as it turns out - hemorrhagic).

I also thought about death a little bit today. That last patient there - she had a 5x6cm bleed in her head and was on warfarin and had probably been oozing for .... 17 hours. She had a very bad prognosis. So, on admission, we discuss with him whether his previously healthy wife (who is in her late 70s) would want to have an ET tube. "NO". What about compressions, medications, or cardioversion? "NO". So, this is a woman who was previously functional, who will likely be dead by the time I return to the hospital in the morning. It makes me feel a little dirty to say, but it was refreshing to see an appropriate DNR order - one that I felt I might make myself. She and her husband had talked about it before. They'd been happy and had led full lives. Neither wanted to burden the other, so they didn't.

It made me think of my Grandpa; he's 95 now. He'd been healthy, living more-or-less on his own until about 90 when my Grandma died. He was quickly moved from Florida up to NJ to be near my aunt. Since then, nearly any time I talk to him, he tells me how he's ready to die, "What's up Grandpa, how was your day?" "Just another day to wake-up." Serious depression. He watches all of the people in his nursing home die. He's now been hospitalized 3-4 times in the last year, bilateral hip fractures, sepsis secondary to UTI, and pemphigus. He just keeps ticking. He seems fixated on death when I talk to him, but he still seems terrified of it. I sometimes think things like, "he might be happier if he didn't have to continue this" and then finding myself feeling like a complete ass for thinking that. And then I argue with myself about it.

We can keep people alive forever - but should we?

Journal club (minus the journal).

I feel like an idiot. Tonight was journal club and I was on the presenting team. It was me, DB (another 2nd yr), DS (an intern), and MA (a third year). The topic was selected about 3 weeks ago - Contrast Induced Nephropathy. The articles were sent out 2 weeks ago. I printed the 3 out and read them on the plane on the way home from vacation. I got my assignment for journal club - write-up our discussion of the articles and a brief summary of each to be mailed to the people who couldn't attend. Huh. Only 2 of the articles will be presented - one by DB & one by DS. MA and I will not do any speaking at journal club. Huh.

So, I spend about 4-5 hours in advance of JC putting together a hand-out nicely summarizing the articles and including a discussion of positives and negatives. MA then tells me that I shouldn't bring it but just add whatever additions we have from JC to it and mail it out later. Huh. So we do JC, the 2 articles are presented. I sit back and take furious notes. At the end of it, the facilitator (a little drunk on wine) looks over at me with a questioning look. Later he says, "I thought you were presenting" and walks off. FML.

What a stupid change to the JC procedure - one person to just make notes and not actually present an article. *sigh*

In other news, I have a trad climbing class lined up for myself to get my trad climbing chops back. Furthermore, PittStain, I had already spent some time on summitpost and I greatly desire a return to Seattle for perhaps a rendezvouz @ 14,411 ft. Just saying.

Looking toward the future -- I need to figure girls out.

Epileptics have seizures!?

Today I relayed to my attending the enjoyment I was getting out of spending more time with patients and the leisurely consult. This was quite apropos as I had just finished seeing and writing up my first consult of the day (started @ 8am) and it was 10 am and it wasn't until 11 am that we finally left that area of the hospital. Yea, that's right, between 8am and 11am I saw, count 'em, ONE patient. Neuro is chillax. What's nice is that my attending does appreciate that I take a more thorough inpatient approach instead of the quick-and-dirty that the ED often forces.

I did see an interesting case today - Opsoclonus-Myoclonus. This dude's eyes were off the charts with flutter. The afternoon was pretty benign with another consult on a lady with epilepsy who, dum-dum-dum, had a seizure!!!! Then I got sent home early and took advantage by climbing for a few hours and then heading home. Climbing was good - I found a guy to take the trad course with me. It's a $200 investment, but something that I think I need to do in order to feel like I'm (1) getting outside here in NC more and (2) advancing in my climbing. I'm not in college anymore. I don't have at my disposal a killer outdoors club with free stuff. I have an income and enough money to spend on myself. It is OK for me to take advantage and try to make myself feel like a climber again. :)

And now I'm an MS-3

Yes, I would definitely rather be in the emergency department with my days, but I have to say, there is something nice about having unencumbered time to spend with a patient. As of late, I've taken to making my neuro consults extremely leisurely. I do a bit of a chart review for 10-15 minutes followed by a 25-30 minute history and then a comprehensive neuro exam is another 20 minutes. It's like being a med student again, except when I leave the room, I have some idea of what is going on. One of the things I am finding that I like best is it gives me time to formulate some kind of a relationship with the patient as a person. I think it makes me finally realize what they always talked about in medschool during 3rd year - "You will have more time than anyone else to spend with the patient. Learn about them as a person and better understand their disease." Frankly, during 3rd year, I was running around so much trying to learn or impress my attendings, spending time with patients never made it that high on the list. Now, as a second year resident on an off-service elective month, I am finally beginning to see it. The first 2 patients I saw (who each got about an hour with me) both said they really enjoyed my company. And both of them, as it turns out, were probably more psych than neuro issues; and maybe, just maybe, my time helped them relax enough to feel comfortable going home.

The rest of the day was fairly benign. Eventually I left the hospital at 6pm and then came home with the intent of finishing my journal club presentation in 2 hours and then maybe making it to the climbing gym. Sadly, it ended up taking about 4 hours. That being said, I haven't sat down and worked on producing something, even something as stupid as a write-up for journal club, in a long time. It felt kind of good. Maybe getting into research and this national stage will actually be a good thing.

I also heard from "B" tonight. Not really sure what to make of it. She and her boyfriend separated because she still has feelings for me - we haven't been in contact in at least 2 weeks, spoken for over 4 weeks, or seen each other in maybe 2 months. Maybe he just broke up with her. Or maybe we like punishing each other. At this point, I don't even know how I feel. I certainly miss having someone around but I'm also looking at this as a point in my life where I'm trying to effect a positive change in my life. A moving forward. Looking inward to re-grow outward. Talking to people, learning (and remembering) names. People are people. I think i'll just keep my distance for the time being and see when, if ever, our paths ever cross again.

Tomorrow night ... I think I'll climb.

Rebirth.

I think that, in the last year or few, I've lost a bit of myself. I hate to blame, so I won't. Instead I'll simply say that I seem to have moved away from introspecting and have moved more towards simply passing time; or, more clearly, letting time pass me. I feel more like I'm letting my life pass me by. There are things that I used to do that I have just stopped. I want to remember them. I want to feel things I haven't felt in a long time: passion, excitement, trust, fear. I want to be able to talk to people again instead of the stilted topical conversations that seem to spring forth from my lack of insight or emotion. I want to think about the patients that I see as people; I want to think about their lives, their families, and how everything that I am doing, affects them. I want to re-connect with myself and with the world.

Yup, that's pretty vague but it's a start. Let's see if I can't write something each day. Let's see if I can't just formulate an opinion - something exciting, angry, optimistic, or conciliatory - but still *something*.