Sunday, May 24, 2009

Happy campers

Brian and Sam are home safe from camping. They had a wonderful time -- and brought home some great pictures.

Saturday, May 23, 2009

And just like that

Medical school is over.

Yesterday was my last day. As last days go, it was lovely. Conference was canceled, so my residents and I lingered over lunch at an outdoor campus cafĂ©. Feeling expansive, they sent me home early. I walked out of the hospital and back into the sun, and I thought about how the next time I walk through those double doors, I’ll be a doctor.

Today, I feel strangely weightless. My guys are gone for the holiday weekend, camping at Little Basin with some friends. I took the opportunity to sleep in ... then I got a facial at La Belle ... I'm sitting at a coffee shop, wondering what I'm supposed to do with myself now. I mean, seriously, now what? It's disorienting: at age 29, after 22 years of school, I'm no longer a student.

Of course, in the most practical sense, now what? is a simple question. This weekend, I'll rest some and undertake a few preparations for our trip to Indiana next week. This month, I'll play with my son, spoil my husband, and try like heck to get organized for my internship. And next month, of course, I'll walk back through those hospital doors. But today, I think the thing to do is just to sit still and try to absorb the in-between-ness I'm feeling right now.

In that spirit, here are some pictures Brian took of me and Sam at the park last week:

Friday, May 15, 2009

The unit

I’m now three quarters of the way through my ICU rotation. As I expected, I’ve liked this month quite a lot – interesting pathology, great colleagues, free lunch. Also – unexpectedly – decent hours. My strong preference is to work early-to-early: I like to arrive at work early and leave early enough to spend meaningful time with my kid and husband in the afternoon and evening. These days I tend to get in around 6:30 and I’m usually out the door by 4. Miraculously, medical students in the ICU have weekends off. So, I’m happy: between the ICU and mothering Sam, life is good.

But here’s an ICU tidbit for you: at Stanford – to be fair: Stanford is not known for Wal-Mart prices – ICU beds cost in the range of $30,000 a day. And that’s just the bed! $30K a day before the patient gets a single CT scan, dialysis treatment, liver transplant, subspeciality consult or – as a patient of mine received yesterday – 150 grams of donor derived albumin. ICU stays easily and frequently run to the seven figures and as much as no one wants to think about it, let alone talk about it, the cost of intensive care is a real problem.

There’s a patient on our team, insured by the state’s Medi-Cal program, who has been in our medical ICU for weeks. When she was admitted, the cause of her severe and refractory respiratory distress was somewhat mysterious. In her late 50s, she’s a cancer survivor who received radiation treatment to her chest earlier this year. (Radiation pneumonitis?) Then, midway through her ICU stay, she was found to have a significant burden of blood clots in her lungs. (Pulmonary emboli.) Now, she has a ventilator acquired pneumonia. So she’s been treated for this range of maladies (steroids! Anti-coagulation! Antibiotics!) over the course of the past three weeks and the effect has been … nil. She’s still desperately dependent on the mechanical ventilator to breathe. Worse, her pain and agitation have been exceedingly difficult to control; she vacillates between significant sedation and sedation “holidays” that aren’t fun for anyone, especially the patient and her (equally agitated) nurses. My attending has expressed near certainty that she will never again breathe on her own. Her lungs are too stiff and too scarred. Despite our range of treatments, her morning chest radiograph looks just as bad now as it did when she was admitted. (To wit: it’s hard to see her lungs at all. “White out”, the radiologist calls it.) In fact, there is unanimous consensus among our ICU team that the time has come to withdraw ICU support and to help this patient die comfortably and with dignity. And yet – understandably, I acknowledge – her family continues to drag their feet in a frustrating cycle of missed family meetings and refusal among her adult children to make a decision regarding their mother’s care unless the entire family quorum is present. So we continue to prolong the slow and tortured death of this woman who alternates between sedation and frantic agitation, breathing at a rate that’s more than twice normal. And we continue to spend money at an equally alarming pace: $30,000 or more a day from the California state coffers at a time when our fair state is running a $40 billion deficit.

It’s frustrating to say the least. No one seems to know what to do.

Sunday, May 10, 2009

Happy Mother's Day!

I'm enjoying the heck out of my second Mother's Day. Breakfast in bed, a luxurious morning (coffee shop! park! library!) with my husband and son ... and now, time to blog in my bathrobe.


My Mother's Day gift to the mothers reading this post is this video. It's long, but worth it. I tried to reserve the related book at our local public library, but discovered that there are ten people in line for the book before me. So I think we'll take a Mother's Day trip to the bookstore and pick it up today.