Friday, July 25, 2008

Going to die in jail...

Hospitals are really jails in disguise.
It's unbelievable how many of my patients are in 4-point restraint, all for a variety of reasons.
One of them is a mentally retarded young man whose childhood is ravaged by constant seizures - he pulls out his NG tube twice a day because he hates them, but the tube is the only way to reliably feed and medicate him. Hence, everyday is a game of perseverence, to see who will give up first - the doctors putting the NG tubes in or the kid pulling the tubes out. There are many other things wrong with this case, but it is beyond the scope of our topic today. We'll call him Mr. G and we'll come back to him another day.
Another is altered and his only instinct is to leave the hospital (isn't it funny how no one wants to stay in the hospital and be healed?). And so he is restrained. I was walking past his room when he flagged me down, asking for help to get up off the bed. I innocently went to the nurse and asked for assistance, when she told me the patient doesn't know what he's doing and there is no way he's getting off that bed.
Another man is a true disaster of 4-point restraint. He was a young vibrant man when he came in with encephalopathy. He then went into a coma and is now slowly coming out of it. The disastrous part is that he is not conscious enough to voice his desire in an understandable way, but he is conscious enough to try and escape from his bed. So what do we do? We sedate him, to prevent him from leaving in his half-altered condition, but also to delay him from ever gaining his full consciousness. And thus everyday we set him back from recovery with Haldol, so that the nurses and the doctors are not bothered. I wonder if he will ever get out alive.
Many times I hear people begging and screaming for water...and the screams go unnoticed. As a medical student, I have to bother the scary nurses for permission to provide screaming patients with water, because some of them may be NPO, and some attending surgeons may literally kill me if I set back their scheduled surgeries with drops of water. But NPO is really a euphemism for starvation, and it is a brutal penalty. Many times patients are held on NPO for many days as the surgery date keeps getting rescheduled at the convenience of surgeons and at the mercy of hospital politics. It really is a form of torture.
Many hospital prisoners are allowed to execute themselves. How? We leave old, frail patients alone in their room, and as they get up, they are bound to fall, hit their head, and never move again. I can't count the number of patients whose plugs are being pulled this week - some of their deahts will be a direct result of hospital negligence and lack of fall precaution when one should have been instated.
So what do we get when we add 4-point restraint, torture, mind/behavioral control with sedation, and execution together?
We get a US hospital. There is one right where you live. And once you agree to enter, you'd better hold on to your consciousness. If you become altered, you may never get to leave ever again. If you don't listen to them, they will restrain you. If you try to escape, they will quiet you with sedation, and you'll never live to tell anyone what happened to you.
I would never want to be in a US hospital, not as a doctor and definitely not as a patient.

Thursday, July 17, 2008

Too tired to write about everything...

But I just want to document this episode for myself in the future, so that I do not lose sight of what medicine is and should be.
Today I fed someone his whole dinner because the guy was disabled enough that it is difficult for him to eat by himself, but he was not disabled enough to require someone to help feed him. He was stuck in this limbo that makes it really excruciating to watch him eat on his own. The funny thing is I don't think I've done anything remotely close to healing until today. As a medical student, I'm useless and mostly counter-productive in the medical system - it only tolerates me because without me there will be no future doctors. The most I can do is to call people for follow-up and look up labs by taking twice as much time as a resident would.
Most doctors would think feeding a patient is a nurse's job, and the nurses are too burnt out and exhausted to sit down and patiently feed him. But I think as so-called "healers", we should be forced to engage in these types of activities that immediately and directly help the patients - most of the medicines and the procedures we prescribe to cure people probably make them sicker than when they walk through the door, so who's to say that these acts of kindness and caring cannot heal better than CT scans and metformin?
I think this whole education process makes us lose sight of what healing really is. Radiologists look at pictures of people's brains and claim that they are healing people without ever speaking to them or touching them - now what kind of healing is that? Other doctors walk in and out of patients' rooms, order tests that cover their organs and disregard other health problems smoldering in other parts of the body - now what kind of healers heal only one organ and not the whole person? The more I think about it, the more I am convinced that nurses or home-aids, who interact with patients directly everday, giving them medicine and wiping their foreheads when they spike a fever, are the true healers in our army of medical personnel.
The guy told me he has never had it this good (us feeding him with patience) and he really appreciates our help. I don't know if I should jump for joy because I made someone happy, or cry because this guy doesn't get the high standard of care he deserves everyday

Friday, July 11, 2008

The Battle for My Soul

Today I concluded my first week of third year, and today is definitely the most intense day I've ever had so far. I think it is because all the human drama that has been building up all throughout this week ended with the epiphany of modern medicine in its ugliest and truest form - when the exhausted ER residents can no longer be bothered with politeness, and when the lavish lobby and colorful gift shops are stripped off to show the dirty, cop-ridden ER of Elmhurst.
I will just head straight to the epiphany - I will not yet bother with subtle things throughout the week that represent the uncorrected remainings of bad medicine, the complicated mistakes that patients rarely see.
Our Neuro consult team got called down to the ER today to see this old Korean lady who had diarrhea and lethargy prior to admission. She then became unarousable by her daughter, who promptly called 911. We arrived to find a frail, white-haired lady tugged away in the corner of the cramped ER ward, manned by her daughter. The interpreter service is unavailable in the ER, as there is no phone anywhere near the beds. We proceeded through our neuro exam awkwardly - maybe because the daughter could only speak minimal English, or maybe because the patient was a bit altered. We left with some promising exam results, but a part of me felt uneasy for reasons I could not pinpoint. In hindsight, I was probably bothered by the fact that we could not get an interpreter when one was warranted, and that the patients appear neglected, even though none of them asked our hoard of doctors for help. I think it's the way they looked at us, as if they need help but they knew that we could not help them - not because we do not want to, but because the system taught us to only relay the information to the overworked ER doctors and continue on our merry way - because that is how things are.
It did not hit me until we returned a moment later to perform further neuro exam. The lady was alone, agitated and was determined to climb out of bed, unaware of the chaos around her, nor of the overworked nurse who roughly stripped EKG pads from her chest in order to move her to another spot. It seems that when this patient became altered and confused, the inner instinct that remains at her core tells her to go home. We approached her, and as the other doctors tried in vain to talk to her, I said hi in Korean. My heart leapt when she immediately turned to me - then she started gesturing that the IV in her hand is paining her. I could not say anything else in Korean, so I gestured to her that she should wait until we found a staff who can interpret. A Korean cop came to interpret for a while, but that did not do much good since the lady seemed too confused to even understand her language. In the midst of this attempt at adjunct interpretation, her son came to the scene. We then told him to ask her a simple neuro exam question:
Doctor: "Can you ask her if she knows who we are?"
The son followed instructions, and reported that she answered no. He then engaged in a back and forth conversation with his mom, as the doctors observed and waited patiently for the findings. After a while, he paused, coping with everything that just happened, then uttered in a quiet disbelief...
"She does not know who I am"
I looked away to hold my tears. In that lonely chaos, I did not know if I should feel sorry for the old lady who had no idea what was becoming of her, or for the son who learned for the first time that he has lost his mother, the personality and the memories that make her his mother and not a few pounds of flesh. Looking back at her stretcher as we were leaving the ER, I can see myself standing in the shoes of her son - standing, because there are no chairs for family members in the ER - guarding the fleeting remaining of a stroked out loved one, waiting in the nerve-wrecking anticipation that one of the many armies of doctors will eventually come with a solution and not more questions. In the midst of arguing nurses and scary cops, the helplessness around that ER ward was overwhelming -everyone from all walks of life came to this ER and had no choice but to submit to the mercy of the medical system - one that is broken, overworked and unkind.
The scary part for me was that I wanted to cry, but it would have been inappropriate to cry then. So for the rest of the day, I held up the tears in their fort, waiting for the opportune moment to "feel". In order to appear composed and appropriate in the eyes of colleagues and patients, my soul became a numb existence - a functional machine with no sympathy. There are two paths towards MD - the path that is art and the path without art. The path without art numbs us from the human drama that is life and death, so that we can function. It is the opposite of art, where you give up your soul to emotions and feelings in order to create. The path that is art teaches us that medicine is barely a science - it is an art - the art of calming down the agitated, the art of delivering bad news, the art of following our instincts instead of impersonal numbers in the NEJM that may not apply to the human flesh sitting in our office.
And until I hang my white coat, everyday is a battle for my soul.

Thursday, July 3, 2008

The Calm Before the Storm

There is not a more fitting title to this entry - I feel curiously calm, even though the storm is in sight. On Monday, I will depart the realm of being a second year medical student, where mistakes can be forgiven, to the real world as a third-year medical student in which my actions have consequences, both insignificant and dire. My decisions may not dictate life or death, but they can make a big difference in non-obvious ways. I can only pray that my bright-eyed, optimistic attitude will stay with me when I pop out the other end of the third-year tunnel, and that I will remember that my duty is to serve others - this is not an egoistic game of puzzles in which I race to the one, correct diagnosis, the way House does. No, this is not about the doctors - it is about the patients. It is about what they want, what they need, what they become, and there is never one, correct diagnosis. Health is a complicated interplay of factors that can never be handled through a single diagnosis, and I again pray that I will be as thorough as I hope to be. My biggest fear is that the monster that is the medical system will strip from me the passion, the patience, and the kindness, all of which are vulnerable to fatigue and competition. I feel it slipping away as we speak - part of it became casualties to the gruelling board studying and various events of second year. One thing I can hold on to is the exciting curiosity to learn and excel at neurology, my first rotation. I believe in hard work and the gift of intelligence given by my genes+environment - the power of the two combined should overcome any obstacles, and there will be no excuses to fail.
I can only hope that this entry will keep me grounded and focused until the journey through this black hole comes to an end. Do you remember those exercises in high school, where you write a letter to yourself 10 years in the future? This is one of those letters, and I hope it reminds me of me, before the transformation - good or bad transformation.
Entries after this one, hopefully many, will record encounters throughout this journey, life-changing or petty.