pencilandahacksaw

First death

pencilandahacksaw:

These past few days have been an emotional trainwreck full of firsts for me, but today is the first “first” that I’ve had to share with a group. The class was at the hospital waiting to be tested on exploration of the abdomen, and the first student had just started when the doctor was called to a code across the room. The code was for an infant who couldn’t have weighed more than 3 kgs whose heart had stopped.

He quickly intubated as a nurse started a cardiac massage while another injected adrenaline. After a while he decided to perform a venesection of the left exterior jugular vein so that the kid might at least have a snowball’s chance, but the vein was too fragile; had he kept on trying he would have most likely bled out. While all of this was happening the child’s heart stopped 3 time and another 6 doses of adrenaline were applied, but after the first event one look at the pupils and you knew.

The doctor left a nurse to apply pressure to the vein so that he would not bleed out and informed the parents. No more could be done. He told us that the infant had come into the hospital with a terrible outlook - he had a slew of malformations, not the least of which was that he only had half of a heart. The parents had already been informed that the odds of their being able to take their child out of the hospital were slim to none, but that did not make things any easier for them. As I walked out I could see them in a corner of the hallway, huddled in each others arms. I walked by and said nothing. What words could I offer to the parents of a child who was now for all intents and purposes dead. 

This has not been a particularly good week.

Two patients

I was in radiology class and we were looking at the case of a 75 year old woman. She arrived at the hospital due to the fracture of her left femur at the neck, and later because of neurological problems. He then presented the case of a 45 year old woman with severe back pain. After showing use the X-Rays and CT scans, he told us that they both had the same affliction, but at varying degrees.

Naturally one would think the older patient would be more advanced, but after really looking at the X-Ray you could tell this was not the case. They both had multiple myeloma, and it was so advanced in the 45 year old that the doctor remarked that her skeleton looked like swiss cheese. And he was right; practically every one of her bones had lesions. 

After we had discussed the case and gone over all of the imaging results the doctor made a statement that I will paraphrase since he said it in Spanish and also I don’t remember it word for word:

"Please remember that the cases that I bring, that the doctors at the school bring, are great teaching tools because they are fascinating medically speaking. In my eight years of practice I have only seen three cases of multiple myeloma, and these two were just last month. We have to remember that while they are interesting academically speaking, these cases are devastating to the patient. Go home and look up the treatment and prognosis for multiple myeloma. You have to remember that these cases were not pulled out of thin air; they are real people, and they are suffering."

I think this is something that is very easy to forget, and every health professional should be reminded of this from time to time.

First Death

I was sitting in my hematology class, really struggling to stay awake (sitting at the very front of the class in fact did not help at all and just caused the doctor to shine the laser pointer in my face) when the doctor began to relate a personal experience.

The doctor giving the class was of course a hematologist, and in this particular class we were going over normal values of a CBC and what to look out for. He put some values on the board, and we were tasked with figuring out what was wrong.

hemoglobin < 10
leukocytes < 3,000
neutrophils < 500
reticulocytes < 0.5%
platelets < 100,000

No one in the class knew what exactly was wrong, but we all knew that something obviously was as all of the values were well below normal. He went on to tell us that when he was working in a clinic in a village the parents of a 16 year old girl had brought her in with values that fit these criteria. He suspected many things but chalked it up to a malnutrition problem and left it at that.

The girl kept coming back and though she had improved, was still well below normal. Finally one day he saw the girl’s father who had come to visit the clinic to thank him for everything he had done, and to inform him that the girl had died.

Stunned, he asked how that was possible, and the father gave him the medical report of a hospital they had taken her to in the nearest city, where the physician had noted that the values were obviously signs of aplastic anemia, and criticized the village physician for missing the obvious Camitta’s criteria.

The class was quiet and really listening now, as he said that while the girl may have died anyways, it was his shortcomings and inability to read the CBC report well that led to her death.

He said that he recalled the saying that you are not a doctor until you have killed someone, but that ever since then he dedicated himself to reading the blood work as best he could so he would not miss something like that again.

He told us the vast majority of doctors have no idea how to really read a CBC, which was a shame since if they could master that there is no telling the amount of lives it would save. It is “just” a simple sheet of paper with numbers that are commonly just glanced at when they hold so many answers.

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Regional Hospital

Seeing as how the doctor is a pediatrician, and we were on the pediatrics floor, it was no surprise that the patient was a 7 year old kid. What was a surprise was how lively he was.

He’d come in about a month ago and was diagnosed with hepatic cancer after they found a tumor on his liver, but you’d never think it by looking at the boy. He was chatty, curious (practically choked me when he grabbed my stethoscope and was in awe when he listened to his heart) and devious, as his mother joked about how he flirted with the female doctors.

The only obvious signs he was sick was the fact that he was bald (from the chemo) and the scar on his right side where they had biopsied the tumor. On the physical exam the liver could be felt below the rib cage (which it should not be).

It was very odd to see such an obvious kid asking the nurse if he could walk around and playing with some plastic toy cars after being told no since he had a chemo session later and should rest. Most of the kids I’d seen up to that point that had cancer were quiet and tired, a result of the chemo and being in a hospital bed for so long. I guess what threw me off was that he was still acting like you would expect a kid to. I hope next time I see him his demeanor will not have changed too much.

I went to the regional hospital, a short 10 minute trip from where I live, for my dermatology and infectology clinic hours. The first difference that hit me between that hospital and hospitals in the US was that it was far busier. Granted it has been years since I have set foot in a US hospital, so my memory could be wrong, but this place was packed.

It was cooler inside than out, but not by much. Patients, family members, and medical staff struggled to get in through the main door, where a guard was making sure that nothing went wrong as we all tried to squeeze through the entrance the size of a normal doorway. My group of fellow students was lost for a while since no one had told us where to go, and the hospital staff were of no help (and who can blame them; I hardly expect them to know where a specific doctor is at a given time).

We finally found our doctor after calling the school for information, and were given the introduction to his class which consisted of all 18 of us crowding into an empty patient room as he gave a PowerPoint presentation of what was expected of us in a low tone, as a meter away newborns were resting in incubators.

For dermatology we had to split into two groups, as all of us could not fit into the small room that could not have been more than 2m x 3m. The doctor called in 4 patients, one by one, and gave us a run-through of how to interrogate a patient, how to write down the case details so they were ordered and logical, and the dangers of inferring or leading the patient.

All in all it was enjoyable, but also immensely daunting to think that one day their abilities will be expected of me.