Thursday, December 09, 2004

16 Days to Christmas...

It's another one of those days.
I feel dumb. I just have trouble working with this colleague. She's one of the seniors on cardiology as well. And she happens to have the day after me for call. Anyway, technically, call begins at 7am. So at 7am, the seniors are supposed to pick up their call pagers, including the hated code pager. But this girl has been coming in at 830am for call, leaving me with the pagers until then. In fact, I had to run a code at 815am postcall last week, when I had already been awake for over 24 hours, and this was during her shift. Anyway, I just bluntly told her today, call begins at 7am, so I would appreciate it if you could pick up the pager at 7am. Last I heard, she's pissed at me now for making her come in early. This really gets me; she leaves at 3pm every day, leaving the other seniors to supervise her interns. And she always comes in late. She has no right to be pissed now. And the dumb thing is, I'm upset that she's pissed. I came home thinking, should I have kept quiet and pick up her slack instead? Intuitively I know I stood up for what was right. But I suppose it's human nature to avoid conflict.
On another note, I struggled with this difficult patient too today, and this just spoilt my day. 64 year old male who had an invasive left upper lobe adenocarcinoma of the lung, with what appears on CT to be adrenal and thoracic nodal mets. The tumor basically invaded the aorta deep enough to cause a large thrombus to form. So, he embolized some of this to his coronaries and presented to us with a non-ST elevation MI (NSTEMI). Also threw some to his brain and stroked, presenting with cortical blindness and mental status changes. We also found infarcts in the kidneys bilaterally and spleen.
The family was adamant about doing the full cord press. Full code, wanted us to do parenteral nutrition or even PEG tube feeding. Wanted surgery, chemo and radiation.
I had to sit them down today to review what the neurologist, oncologist and cardiologists (us) were saying. Doing more would prolong only his suffering. It's time to let him go. Time to heal and comfort, not to cure.
In the end, they tearfully decided to change his code status to DNR (Do Not Resuscitate). And we'll start looking for a hospice facility for him.
What a day. How does one come home and pretend he or she didn't just have the most heart-wrenching conversation about letting go? Dying. How does one go on with life, with so much death around?
This makes every thing else seem so... umimportant.


Blogger Kath said...

You were right to tell her. Basically you should have told her (politely) the first ime she was late. She is going in to "your" energy. Energy you can defenitely use for all other sorts of things.

And ehh, good job with the family of the 64 year old male.

9:38 PM  
Blogger vagus said...

Thanks. It's a difficult situation, but i hope his family's able to find peace. I can't even begin to imagine what i would do if i were in their shoes.

11:07 PM  
Blogger YeePei said...

Ultimately the family will understand that there's only a limit to what can be done, and they will come to realise that letting go is actually a better option and also kinder option to the patient. Making the decision is painful, but it is something that has to be done. Then again, that's life. It's tough.

3:00 AM  
Blogger vagus said...

Unfortunately, not all families understand that. And medicine these days can do a lot to harm as well.
I remember this case of an elderly guy whose son was a doctor, who presented with acute leukemia in blast crisis, AND low-grade DIC. His son pushed him to be full code. Not the right decision. The code team couldn't bring him back, but he suffered right to the end, with the tubes and the bagging, and the bleeding.
Sometimes families have trouble making the right choices.

3:22 AM  

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