Category: Nonfiction

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Nonfiction Observations

Boundaries.

A bus approached the curb and I looked up from my book. It took me a few seconds to realize that he was talking to me.

“Dr. Chang? No, Dr. Wang. It’s Dr. Wang, right?” he called. He slowed the pace of his walk. In one hand he clutched a plastic bag filled with loose papers. A backpack bounced against his shoulders. Though it was a crisp autumn day, he wore only a tee shirt one size too large for his frame and had tied the arms of a jacket around his waist. The hems of his jeans were frayed.

“Hi,” I greeted, trying to recall his name. I hadn’t seen him in nearly six months. He stopped and extended his hand to shake mine. His skin was softer than I had anticipated.

“Dr. Wang, I don’t like how they’re treating me at The Clinic,” he began. “They don’t know what they’re doing and I’m done with them. I think they’re working with the FBI, Dr. Wang, but I can’t do anything about that. I don’t feel safe in my apartment and they know this. They’re bugging my apartment. I don’t know what the FBI is looking for, but would you want to live somewhere that is bugged? I don’t. I’m done with The Clinic, Dr. Wang, I really am. What do you think I should do?”

He stood still, waiting for an answer.

Pedestrians filed past. Buses roared along the street. An occasional yellow-orange leaf fluttered to the ground. A dozen people looked down the avenue, looking for their bus to whisk them away.

I opened my mouth, still uncertain of what to say—

“I’m sorry,” he interjected. “You’re not here to provide psychological help right now.”

Before I could reply, he began to turn his body away from me.

“I’m sorry, Dr. Wang.”

He began to walk away as the bus I wanted approached the curb. Before stepping towards my bus, I looked back at him.

“Have a good day, Dr. Wang!” he called, waving at me. I waved back.

As I boarded the bus he looked back as he continued to walk forward. Over the heads of the people between us he shouted: “Thank you, Dr. Wang! THANK YOU!”

Categories
Lessons Medicine Nonfiction Reflection

A Dream.

A few days before I learned what happened, I had a dream about you. When I awoke, my heart felt like a bird flapping its wings inside the cage of my ribs.

The details had vanished. Only anxiety remained.

I gasped when I learned what happened. I suddenly remembered the little details, the things that never made it into the clinical notes: You liked your coffee black. You read the Wall Street Journal. You missed driving your sports car.

Where did you kill yourself? Did you get a motel room? Were you outside? What time of day was it?

You certainly planned this. When did you make the final decision? Did you waver? Did you want to waver?

They say that there are two kinds of psychiatrists: The kind who have never had a patient commit suicide, and the kind who have had patients kill themselves.

I now belong to the second group. We all join the second group at some point.

I wish you hadn’t killed yourself.

I thank you for what you have taught me, both in life and in death.

I wish you had the peace in life that you thought was only available in death.

May peace be with you now.

Categories
Medicine Nonfiction Observations

I Remember.

I remember when we dragged ourselves to the large lecture hall every morning, backpacks slung over our shoulders and cups of coffee in our hands. Six to eight hours of lectures awaited us.

I remember where we all sat in that lecture hall. I remember the future ophthalmologist who sat behind me and made snarky comments while certain professors gave their lectures facing the chalkboard. I remember students sitting six rows behind me who told me after class, “We saw you falling asleep today. If you sit in the back, it won’t be as obvious.”

I remember the guys throwing around a fluorescent Nerf football between classes. Some of them would take off their shirts (and one would look around to see if women were watching) and relive their days of playing college sports.

I remember when we wore shorts, tee shirts, sandals, tattered jeans, dangling earrings, and tank tops.

I remember going to parties and watching people drink wine and beer out of those red plastic cups.

I remember when we received the short white coats. I remember how stiff they were, how awkward we looked in them, and how annoyed we were that we had to buy “nice clothes” in preparation of training in the hospitals.

I remember that we exchanged ideas of where to find “nice clothes” for “cheap”.

I remember how tired and haggard we looked after we took call. I remember when our scrubs were wrinkled, our hair was unkempt, and our hygiene was suboptimal.

I remember when we wondered how we would ever survive our intern year.

I remember when we contaminated sterile fields and didn’t know what size sterile gloves we needed. I remember certain nurses rolling their eyes and yelling at us for our ignorance. I remember when we would see each other in the hallways and stairwells, holding order sheets for signatures, carrying baskets filled with gauze and tape, and trailing behind the medical team that was into its third hour of rounding.

I remember when we tried not to cry when attending and resident physicians said unkind things. I remember when we shared strategies about how to manage certain doctors. I remember how much we said, “I don’t know.”

I now see current photos of my classmates from medical school and, to my surprise, they actually look like doctors. They have wrinkles around their eyes. The men wear white collared shirts, mild neckties, and dark business jackets. The women wear conservative jewelry and shirts with modest necklines. The long white coats fit their frames. Their smiles radiate confidence.

They look mature.

And old.

Which means I must look that way, too.

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Nonfiction Observations

Contrast.

She was a petite woman. She thrust her shoulders back and her dark hair cascaded down in waves towards her slender waist. Her burgundy and white dress gently bounced with each step she took in her four-inch heels. Her arms and legs had the girths of tree saplings. A designer handbag swayed on her left shoulder and pearl-accented earrings dangled from her ears.

It was crowded at the buffet. With purpose she walked past the glistening hunks of prime rib, the pink slabs of baked salmon, the heaps of bacon, the blobs of scrambled eggs, the bowls of romaine lettuce and spinach, the rounded cubes of honeydew, pineapple, and cantaloupe, the bundles of fried egg rolls, the vats of noodles, the pot of egg drop soup, the bowl of quivering red jello, the trays of walnut brownies, lemon cake, and chocolate mousse pie, the racks of barbecue ribs, the oozing discs of pepperoni pizza, the rows of chocolate chip cookies, and the limp triangles of French toast.

She carried her plate with both hands, her fingers tightly gripping the edges. Her eyes scanned the buffet, but she was not looking at the food. The only item on her plate was one roasted red potato.

Categories
Education Medicine Nonfiction Observations

CPR and Informed Consent.

Radiolab recently aired a show called “The Bitter End” that discusses the end-of-life care preferences of physicians and non-physicians. Physicians are much more likely to decline “heroic” measures, such as CPR, mechanical ventilation, feeding tubes, etc. This comes as a surprise to the hosts and, presumably, to other non-physicians. It’s a good show. I recommend it. (Full disclosure: I like Radiolab.)

In the show, Ken Murray argues that physicians decline these “heroic” measures for intellectual reasons. He argues that we know the data, which includes a study that reported that, of people who receive CPR, only 8% are successfully resuscitated. (Of those 8%, only a portion of them return to their full previous function.)

I don’t think physicians decline CPR and other “heroic” measures because of evidence-based, numerical data alone.

The experience of performing CPR and attending to patients who are critically ill contribute to physician preferences against CPR. It’s emotionally taxing. All physicians have seen the trauma we cause with these “heroic” measures. Yes, performing CPR can lead to cracked ribs and punctured lungs. Mechanical ventilation can lead to severe cases of hospital-acquired pneumonia. Intravenous hydration can cause massive tissue swelling. The consequences of heroic measures are often devastating.

Physicians are taught “first, do no harm.” Sometimes, these heroic interventions seem like they cause more harm than good.

Perhaps physicians decline CPR and other “heroic” measures because of anecdotal experiences and emotions. This isn’t randomized, placebo-controlled data. However, anecdotal experiences and emotions are still data.

Furthermore, there is no true “informed consent” with CPR. When patients are able to consent to CPR, they are not truly informed. They cannot fully appreciate and understand what CPR entails because they have never experienced it.

By the time patients are truly informed about CPR—when someone is pushing on their chests, when a second person is manually inflating their lungs, when a third is injecting medications into their blood, when a fourth is trying to stick a breathing tube down their throats—they are unconscious. They cannot offer or withhold consent.

(This is true with many things in medicine: No one can give true informed consent for general anesthesia, surgery, or even medications. We often only know all the information after the fact. Patients often give consent based on hope and faith.)

Physicians see and treat patients who have undergone CPR. Those patients are usually paralyzed, swollen with fluid, and unconscious. Upon witnessing that, physicians might wonder what the differences are between “living” and “existing”.

This could explain why their end-of-life care preferences differ from that of the general public.