Saturday, January 06, 2007

Quote of the Day

My attending on the stroke service, asking about a patient from whom all life support had been withdrawn: "Well, I checked the obituaries for him this morning, but I didn't see him. I try to read the obituaries every morning to see which of my patients are in there."

Nicely sums things up, I think.

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The stroke service is an amazing dichotomy. Some of our patients recover fully and rapidly, leaving the hospital as healthy as they were pre-stroke. Some will leave for inpatient rehab to regain functions knocked out by the stroke. Some of our patients leave on stretchers, bound for "LTAC" (long-term acute care), to monitor ventilators, IV's, rehab, etc. Some don't leave, and some die quickly. For the 80% of patients who experience ischemic strokes, we can do a lot of things: tPA, keep blood pressure high to maintain perfusion, manage risk factors, etc. For the unfortunate 20% with hemorrhages, it's more a waiting game. Those patients can end up with ventriculostomies, on long-term ventilators, or worse.

I'm not as depressed by this service as I was by pediatrics, surprisingly. I feel like we're truly on the edge, "salvaging" those whom we can, trying to be compassionate to those whom we cannot. My attending does a good job, I think, of doing everything he can for those patients who have any chance of waking up, but conversely, not doing too much for those who don't. We've signed 3 physician's DNR's in the past two days. He's explained to the families that these patients already have severe brain damage, and that he feels it would be cruel to "bring them back from the dead" should their hearts stop, likely killing any remaining brain from global ischemia.

There's an element of selfishness to my train of thought. In really cliched terms, I've had to "confront my own mortality" while on these services. It's not really death I fear; it's pain, or losing my self. If I have to have a stroke, I'd want either a small one from which I can recover, or a huge one that just ends it all immediately. It's the middle ground that scares me. I could learn to live with paralysis, or restricted activity, or other disability; but I like being me. Usually, anyway.

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If you're ever in a coma, one way to assess your level of neurological functioning is to cause pain and observe the reaction to it. For example, pushing the handle of a tuning fork into a fingernail bed would ideally cause a patient to jerk their hand away. Rubbing knuckles deep into a patient's sternum would normally cause the person rubbing to get slapped (take my word for it, it really freakin' hurts). The levels of response (better to worst) are localization, withdrawal, posturing (flexor and extensor), and no response.

What could be worse than a sternal rub, or a fingernail press? My attending demonstrated today, on a patient whom we were assessing for brain death. "You see, you bring down the covers, take their nipple between your thumb and forefinger, pinch, and twist."

@#$@!!!!

The patient didn't respond. The audience (me), however, gasped, covered their chests, and turned away. Apparently, my visual response to someone else's pain is localization, which is appropriate.



And that, my friends, was a day's work on the stroke service.

1 comment:

Jessica said...

Hi,
I have been reading your blog. I'm a third year medical student, too. I can relate to a lot of what you write about. I deal with the depression/anxiety issue as well.
I was wondering what specialties you are thinking about...any ideas?