The Greatest Gift

She was already dead when I came in to work. Blunt head trauma sustained during a common winter activity. Not breathing, and intubated on scene by paramedics. Despite two emergent neurosurgeries, there were no signs of improvement. The day before she had failed neurologic and apnea testing.

For some reason, the weekend team did not want to declare her brain dead the day before, so we waited, as a re-evaluation by neurosurgery had been promised. When I first examined the patient that morning, her family members were yelling at her nurse for not supporting their hopes that she would wake up. I just quietly listened to the patient, and did a quick neuro exam and let them be.

When we rounded as a team, the child's father told us that they were waiting for a miracle. He said that he believed in the Bible and there were cases where people had been brought back from the dead. He didn't believe that God would allow his daughter to survive the accident only to die now. My attending said that he believes in miracles, but that from his exam, the child was clinically brain dead. He apologized to her father, but said that in his opinion, their daughter did not survive the accident. He told them that they should talk to only the loved ones whose opinions they valued. They would have some decisions to make, including possible organ donation, if the child was confirmed brain dead by neurosurgery later as he suspected.

Neurosurgery finally came back to the bedside and the same tests from the day before were repeated. Again, there were no signs of brainstem functioning or breathing. Time of death was declared, and the family was given time to talk with their pastor and social workers.

It was an awkward situation for us to walk into that morning, having not met the family beforehand, but I think that my attending handled it pretty well. I believe in miracles, too. I would have also added that miracles and unexpected outcomes happen in spite of what we do. As a physician, there is nothing that I can do to stop one of God's miracles from happening. Some people recover in spite of showing up late in their disease, while others seek treatment immediately, get treated aggressively, and still die. Life is unpredictable. While I have not seen anyone declared brain dead recover, I have seen a patient recover from removal of life support when it was expected to be a terminal wean. Maybe that's how I rationalize dealing with my own values though, when sometimes families and powers of attorney make different decisions than what I would do. However, at the same time, I think that saying something like that also helps the family to move through their grief. To the family members, there is never going to be an acceptable time to remove life support. They will wait, day in and day out for weeks, and even months. It's horrible to watch families camp out in hospitals, losing sleep and sometimes risking their jobs to be at the bedside of a loved one non-stop, especially when there is not expected to be any recovery.

In the end, the patient's family decided to donate her organs. An organ transplant service was contacted, and they set out immediately looking for matches across the country. Things got a little hairy while we waited as the patient developed renal failure, had great swings in blood pressure and glucose levels, and lost the ability to concentrate her urine (likely due to pituitary infarction). It took about 36 hours of constant work to arrange, but three separate surgical teams were flown in and coordinated to harvest her heart, lungs, kidneys, pancreas, small intestine, corneas, bone, and skin. In the end, she helped about 50 people, a significant number of which were probably children.

I think that this child was part of a miracle, it just wasn't one for her family. It was amazing that she was able to help so many others, and that her family was able to make the decision to donate in spite of the shock of an unexpected death.

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For the last couple of weeks, "Grey's Anatomy" has been focused on a small boy needing organ donation. However, in their scenario, the surgeons are running all over the hospital testing critically ill patients to look for a match, and pressuring their family members to donate. In reality, this is prevented by the use of independent organ donation teams. Once we find a donor (typically emergency and ICU patients), the procurement team is contacted and they come in and run the show as far as looking for matches on the national database.

While it makes for good drama on TV, there are obvious ethical concerns about having the same doctor caring for a potential donor and a potential recipient. We can't randomly test people for matching a recipient without their knowledge, and have no control in regards to what order on a recipient list a patient is. So get it together, TV writers, that was just ridiculous-- I'm not running a chop shop here!

2008 Reading List

Continuing in my quest to read less and less each year:

The Kite Runner - Khaled Hosseini

This book was pretty engaging, an interesting account of the author's life in Afghanistan.

Animal, Vegetable, Miracle - Barbara Kingsolver

An account of a year's worth of sustaining a family by only buying locally, growing fruits/vegetables, and harvesting poultry. Is this really possible? Probably not for your average working family, although it did make me think more about supporting my local economy.

Bringing Down the House - Ben Mezrich

This one had been in my reading pile for a long time, but I had to read it before going to see "21". Still can't seem to win at poker.

I am America (And So Can You!) -Stephen Colbert

If 1,000 monkeys typing on 1,000 typewriters can randomly peck out "War and Peace", this is what 10 crackpots armed with macbooks and endless coffee can do. Ridiculously goofy.

Not So Funny When it Happened - Tim Cahill

I don't remember this one too well, but I think that it did make me smile.

Intern, A Doctor's Initiation - Sandeep Jauhar

My mother sent me this one. It's the story of one guy's progression through residency. He struggles to find balance between family life and work. A lot more sunny perspective than "House of God".

The World Without Us - Alan Weisman

If you suffer from insomnia, this one's for you. There were some interesting points along the way, but so slow and painful.

Into the Wild - Jon Krakauer

Haven't seen the movie. I read this soon after returning from Alaska. Kind of a bizarre story, and tragic to die so close to aid under the delusion of a wilderness adventure. Wondered if the guy wasn't an undiagnosed schizophrenic.

Love in the Time of Cholera - Gabriel Garcia Marquez

Joined a book club, read the book, then missed the meeting (oops). I have another book of his sitting on my shelf, but this one was kind of weird. I think I missed the romance behind the protagonist's delusion that if he could seduce one widow, he was fated to wait out the marriage of his one true love and get the girl in the end. Also, enemas? Not an intimacy to be shared between lovers! Ugh.

You Don't Know D _ _ _

The PICU is running at about half-capacity this week. As a result, we had the Inauguration coverage playing live on the television in Room 1. There were about a half a dozen of us clustered together in there at one point, when suddenly--

"Who's the guy in the wheelchair?" a lone voice questioned.

"That's Dick Cheney, he strained his back packing, or something." I said.

"Who's Dick Cheney?" she asked.

"Only the current Vice President, who's been in office for eight years." scoffed my attending.

"Dick Cheney, you know the guy who shot some guy in the face while he was out turkey hunting," a nurse chimed in. (Well, at least she was sort of right.)

"Oh yeah, that guy... Huh, I guess I've never seen him before," she said, defensively.

There was kind of a long, awkward pause and then people started guessing who Nancy Pelosi was. To their credit, they did recognize Steven Spielburg...

Brr

-11F is really just too silly to go outside.

New Low

The other day I confronted a woman who was seeking pain meds. The medical student saw her first and there were a few things during her presentation that just screamed that this lady was going to be trouble:

1. Abdominal pain x 1 year

2. Recent month-long admission with no diagnosis

3. Multiple abdominal surgeries

4. Allergic to morphine, "Only Dilaudid works"

5. "I need a PICC line, no one can ever get an IV on me."

At first I felt mildy guilty for being cynical, but as the case unfolded, it turned out she had lied to us during the interview. When I had asked if she could be pregnant, she said, "No." When I told her that she was, she said, "Oh yeah, the hospital yesterday said that, too." Her pain had been coming and going for about a year, so there wasn't anything to do emergently besides some basic labs and physical exam.


We got ready to discharge her and she asked for pain meds. As it turned out, she already had a prescription for narcotics from another hospital, but it wasn't very pregnancy-friendly. I don't like talking down to people, but in this case I told her that the only way I would give her a prescription for a pain medicine was if she gave me her other one to destroy. So we traded prescriptions. Let's just hope she doesn't call the other hospital up saying she "lost" their prescription. In the meantime, I've sent a nasty-gram to her primary physician. I will still probably end up with a letter from the Board of Health in a few months letting me know she got multiple prescriptions from different providers, but at least she left my department with a prescription for a safer drug.

Just before discharge, I looked her up in our computer system, and the only thing listed was a previous admission for what turned out to be pseudoseizures and there was a mention of "drug-seeking behavior". When we confronted her, she didn't deny seeking pain meds, but now I wonder if I didn't miss the real diagnosis.

Sigh

I have been meaning to post more, but it's been a busy week with lots of minor headaches.

A couple of weeks ago, I signed up for direct deposit at my moonlighting job. Last week, I got the paystub, but somehow no $ showed up in my bank account. I gave it a few extra days becuase of the holiday, but nothing came of it. So, I went into the bank. I showed them the pay stub, it had the right account number on it, and several phone calls later, the bank manager had it figured out. For some reason, the hospital, despite being given a voided check, put a New Jersey routing number on the account instead of my actual routing number.

So, I called the hospital.

I explained that the wrong routing number had "somehow" been put on the account, the bank was returning the check, and could they please put the right routing number on it to fix future checks. Apparently, this was too much to take in, so I had to wait until the payroll person could get back to me.

The next day, the payroll person calls back. She says that she can't understand why the check didn't go into the account, that she looked up the routing number for Bank of America by my zip code (not New Jersey, btw) and it should have worked. At this point, I tell her that the routing number doesn't have to do with my physical address, it has to do with where the account was opened, and it matches the account number, not the bank branch I visit.

This is where it gets more stupid.

I tell her that the bank account was opened in Arizona, and she says that she's "not authorized to send paychecks to Arizona." I try to explain that when you do your banking with a major company, you don't have to change your account numbers when you move across the country, they stay the original number and routing number as when they were opened. I halfheartedly try to explain how things work electronically and there is no actual paycheck that goes to Arizona and then back here, and that the bottom line is that I just need the right routing number that matches my check put on the account.

At this point, she says that she has to talk with corporate to see how she can get my check out to some bank in Arizona. I tell her that it's not "some bank", it's just Bank of America, with a different routing number than the local one. I mention how at my main hospital, I have direct deposit, and there was no issue with getting it set up. However, she is unwilling to type in the routing number on my check and is hung up on putting in a number by my current address.

At this point, I decide it would be more convenient to just deposit the check in person every two weeks rather than spending more time on this. So, finally she agrees to just continue mailing me my checks. Before she hangs up she says, "And it will be much quicker for me to just mail the check to you, rather than me mailing it to Arizona and them having to mail it back to you to be signed." ARGH!

I have a sinking feeling this income is going to be on both my 2008 and my 2009 W-2's, but I think I'd just rather take the tax hit twice than talk to her again.

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Then there's been the argumentative not-sick people fake coughing/wheezing and not understanding why I can't admit stable bronchitis, the people demanding IV antibiotics when they aren't appropriate based on their culture results, and of course, the "my doctor sent me here for an MRI" crowd.

I'm back to doing floor medicine for the next four weeks. I'm sure I'll be stir-crazy and wishing I was back in the ED by the end of it, but for now I'm looking forward to getting out of the department.

Happy New Year!

Happy New Year! I decided to finish off 2008 by breaking my right pinkie toe. It was stupid-- I was putting away laundry and just managed to stub it hard on the corner of the bed. I've iced it, buddy-taped it, and have been taking ibuprofen when I can remember to. Most of the time, it's fine, but it has caused me to hobble around and try to heel walk on that side at work the last two nights.

Behold, the unhappy piggy (ignore the sad state of my toenail polish):

All in all, 2008 has been a great year: I fell in love, ran a half marathon, had a great Alaskan adventure, and have signed a contract for my first "real" job. My family and friends are doing well, and I really can't complain. Overall, I feel happy and confident, and can't remember the last time that I have had so many things to look forward to.

2009 however, is off to a violent start. I worked the overnight shift, and despite starting out with an empty ED, it was crazy. At midnight we wore party hats and toasted each other with sparkling cider. We potlucked, and waited for the chaos. It finally started at about 1:30. Multiple patients with multiple stabbings, several overdoses, too many head lacerations to count, and every kind of skull fracture/head bleed combo imaginable: depressed fractures, non-depressed fractures, subarachnoid bleeds, subdural bleeds, intraventricular bleeds with impending herniation. That last one is going to turn into the first homicide of the year... our charge nurse was joking at the beginning of the shift that there should be a door prize for the first homicide of the year like there is for the first baby born in a local hospital (yes, we are a dark-humored group).

I spoke with AG this morning, and he sounded in good spirits (although getting tired of lobster, poor boy!).

So here's to 2009: Bring it on!