Be present

So I’ve gone back and forth about whether or not I wanted to write this post, but it seems to be coming out of its own accord regardless. In undergrad, I went to a conference once where I was challenged to try and remain fully present in every moment. To relish that moment, or despair that moment- but to give experiences their due. To fully laugh and to fully grieve, and to honor the space and time where you are. So many times we distract ourselves with food, or TV, or radio, or just looking away. In medicine, there are all sorts of times where you would rather be somewhere else. Generally these encompass all times you are at the hospital between 6pm and 6am and on weekends – which is like, all the time. However, in an attempt to honor the experiences I’ve had this month: I’m taking some time to reflect.

As I’ve said to so many of my friends, delivering babies wasn’t all I thought it would be. I think being there, being present, at the moment of someone’s birth is incredibly exciting and gratifying and a privilege and all that but I’ve found just as much satisfaction in taking care of people through all aspects of their lives. And for me- that was never so apparent as how I felt at the end of one of my patient’s lives yesterday evening.

This was MY patient. I stayed for her admit, I wrote her notes every morning, I spoke with all her consult doctors, I made recommendations, I prayed for her! ( and sadly this is a bit of an exception for me. Generally I’m all about some God’s will but I was really specific this time- Please God let us take her to surgery today!) I was excited to be apart of her surgery- which was bound to be both exciting for me (taking out big masses = big fun) but also a huge relief for her. So often what medical students find exciting is a poor prognostic indicator for the patient involved. Note to all the lay people out there: the more medical students coming to your procedure- the more weird things are going on.

Still, the admission wasn’t completely happy joy joy – we are the gynecologic ONCOLOGY service. Having said that- I was working with the doctor that took all comers, I was at the frontline of disease- and still, as common as big mass = bad cancer, big mass can also = big benign cyst. So there was hope and relief at a final diagnosis and a cool procedure all in one case. And the patient wasn’t half bad herself. She was in her mid 80s and independent. She loved gardening. She had family visiting who spoke the King’s English. Working with resident populations this is a serious plus. – and not unrelated to the kings english and her age- she had teeth! Things were looking up.

And then, her kidneys failed. We did it. Too much contrast in her imaging studies. And then, her heart failure was exacerbated. We did that too. Too much fluid because we assumed dehydration had caused the kidneys to fail. We have a fancy word for this. Designed I think to keep lay people from knowing when to sue- it’s called iatrogenic (we did it) causes or idiopathic (we don’t know what did it). And in old people, things don’t bounce back like they used to. The kidney doctors and the heart doctors wouldnt let us go to surgery. And so all of a sudden this great case wasn’t so exciting any more. We just followed lab values and made her plan for the day before even seeing the patient.

The good thing though, about being a medical student, is that we have time. So I had time to sit and talk to her, and all her consultants, and my fellow residents. I had time to do her physical exam every day. She has no idea how much we were pulling to do something, anything, everyday when we did nothing instead. She has no idea how hard, as surgeons, it was to stop all of her medications, and her IV fluids, and just hope her labs got better. Repeat in your head “Do no harm, do no harm, do no harm”

A few days ago she started to resolve. Good kidney doctors, and more importantly polite ones ( so we would actually take their recommendations), had come on the service and a touch of tweaks here and there and she was peeing like a champ. You hear phrases like that a lot on surgical services “tootin and pootin” “get up thy bed and walk” “take it to the house”. So the decision was made to take her to the OR. I was excited all weekend leading up to the case.

The night before the case the patient vomited a bit taking down her bowel prep. Everyone vomits trying to drink that stuff. No biggie we thought. There was a tiny bit of blood in the vomit but she was on blood thinners we thought. The CT scan showed a partial bowel obstruction but clinically she had bowel movements so no biggie we though. I stayed after hours to be a part of the surgery with another resident. The surgery got pushed back so we were so excited to hear them call down “we’re going to sleep in OR…” I had forgotten my tennis shoes so I was prepping to do this whole thing in heels with shoe covers on.

When we got to the OR anesthesia couldn’t intubate her. There was vomit and stool all over her sheets. Her pressures were bottoming out. She had no oxygen saturation. They were suctioning on one side and trying to find an airway through the other. “She’s aspirating!” people were yelling, calling out for more help. The attending physician, the resident, and I all looked at each other and stepped back.  We cancelled the procedure and told anesthesia to stop. We pulled off our masks, took off our gloves. The patient was “Do Not Resuscitate and Do Not Intubate”. No code would be called.

Talking to the family wasn’t as hard as I expected it to be. Walking the patient back up to the floor to die was just as hard as I expected it to be. In the end, she was extubated at the bed side. Her nurse was mad at us for trying to take her to surgery despite her comorbidities. So no one wanted to be in the room as she gasped. No one wanted to hold her hands as they got colder. So we did. At this point I think all the things we did fer her comfort, were for ours as well. Busying myself with taking off her compression devices, getting her new blankets. Here it took all the conscious effort I had to not look away. To be present in this moment. To be here, and to be sad, and to say good bye while looking at her in the face.

My resident talked her to sleep. We said a prayer. We pronounced her dead with the disposable stethoscope I was able to scrounge up from some where because no one wanted to talk to us and frankly we didn’t want to ask anything of anyone else either.

In comparing my many experiences on Ob/GYN, holding a baby as it is born, holding a mother’s hand during an abortion, holding a woman’s hand as she dies: I find that in either case- there really wasn’t that much I was doing that I learned in medical school. There really is nothing that qualifies me as any better at any of this than anyone else could be. The difference is that while others could be doing these things- we are doing these things.

I’m 25. It’s 5am and I’m right where God wants me to be. What did you do today? And in whatever that was- where you there? Did you look that moment in the eye and give it the time it deserves? Be present.

p.s. Many Blessings R.P. we had a good run.


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