today we had an ethics meeting concerning the care of one of my patients.
she is young, by our standards (under 50 years old), HIV+, infected with a horrible brain disease called toxoplasmosis (the same toxo that can be found in kitty litter, which is why doctors recommend that pregnant women don't scoop it - although most patients with normal immune systems don't get THIS sick - and the danger is more for the baby than the lady) for years. a disease like toxo doesn't go away. you have to take a massive dose of medicine every single day just to get it under control, and then you have to continue to take a slightly smaller dose of medication every day just to keep it from coming back. this woman's partner had passed away from AIDS related illnesses at least a year prior. until then she had been doing well, coming to the infectious disease clinic once a month to get checkups and modify her treatment and pick up cases of ensure. after her partner's death she called it quits.
toxoplasmosis basically eats at your brain. well, it really causes encephalopathy, but in the end it destroys your brain. this used to be a high-functioning woman who owned her own real estate business and raised three children. right now she is bedridden with a nasogastric tube pumping her nutrtion and medication into her stomach because she's simply not awake enough to take her medication by mouth (and toxo treatment requires that you take some medications by mouth - they're simply not available in IV form).
unfortunately, before she reached this state, she had not established a health care proxy - someone to make her health care decisions for her, in the event that she would be unable to. so we had to have this meeting with family members to decide what to do, and to gather their input as to what they believed she would want done. a nasogastric tube isn't a permanent solution (she pulled it out once) and the other options were a PEG (percutaneous gastrostomy tube - a tube directly from the stomach to the skin) or to stop treatment and let her die. even after a PEG tube, there is no guarantee that she'll get better, but without one, she would have no chance.
it's impossible not to become completely cynical and bitter and angry as an intern. some of the more astute readers may have picked up on my less than complete enjoyment of the internship experience from my previous posts. you begin to hate everything. patients become less human, another name on the list, another checklist of things you need to get done in the same amount of time, another "rock" that will never leave the hospital because of any myriad of reasons (they refuse treatment, they refuse nursing home placement, they can't be placed because they've punched nurses/patients in the past, they threw a box of sharps at a doctor, they tear out their IVs/NG tubes/foley catheters every night, they continue to spike fevers despite antibiotics, they use angel dust while in the hospital (i've had two patients have their urine tox screen turn positive for PCP while in the hospital), they're nauseated, their back hurts, their chest hurts, they're anemic, they're vomiting, they had diarrhea, they're depressed, they hate their family, their family hates them).
we look up past information on every patient that gets admitted. this is all past hospital information - former diagnoses, medications they were on, imaging studies that were done, surgeries they had, who their primary care provider is, are they at a nursing home?, etc. we find out very little about their lives outside of the hospital, other than do you drink? smoke? drugs? work? sexually active?
then you have a patient like the one above, who's nonfunctional and nearly nonverbal and you can't get a story from until 2 weeks later when you're at a breaking point so you call the family in and then you finally fill in the blanks and realize that this patient had a life and a family and a business and an apartment and a husband and a daughter who just got married two weeks before admission (and she even attended the wedding). and suddenly the burden you carry feels even greater and even more depressing.
then i come home and i eat dinner and watch reruns and think about how hard and awful and terrible my life is and i become selfish and cynical and bitter again and almost spite the woman for creating more work for me to do and making me stay an extra hour and a half later because of this meeting.
this of course, only breeds more self-loathing.
then i flip open a magazine that came in the mail and read about reasons to love new york, which includes a small blurb on firefighters that died fighting a fire in the bronx earlier in the year. and it includes a passage on a fireman that i helped care for while in the ICU. and i can remember that bizarre night, the first overnight call and first day in the ICU, with firefighters and family swarming the bed. the commissioner of the FDNY was there that night. bloomberg was there too. they turned one of our conference rooms into an impromptu pre-funeral reception, as grim as that sounds. that was one of the longest nights of my life.
then once a month i write something that seems profound but is really just thinly veiled complaints and whining, brush my teeth, go to bed, wake up, shower, iron a shirt, and go back to work and do it all over again, and every morning, before it even turns 9am, i already feel defeated.
merry christmas. don't get sick.
this educational lesson brought to you by dr. j around 9:20 PM | 