Everything I Learned in Medical School: Besides All the Book Stuff (4 page)

Chapter 7

The Cocaine-Snorting Organ Donor

Organ transplants are some of the most amazing surgeries. I’ve always wondered how they can attach every part of an organ into a new body and actually make it work. The answer may be simpler than you think. For example, the kidney basically has three tubes attached to it. One is an artery that supplies blood from the heart to the kidney. The second is a vein that takes the blood out of the kidney and back to the heart. As blood passes through the kidney, waste products are filtered out to create urine, which comes out of the third tube, called the ureter, which is attached to the bladder. And there you have it, the body’s very own purification system. All you have to do during a transplant is attach the artery of the new kidney to an artery in the body, the vein to a vein, and stick the ureter into the patient’s bladder, and you’re done. The process of putting a kidney into a new body takes all of 45 minutes in the hands of an experienced surgeon. It’s pretty amazing.

An exciting part of the transplant surgery rotation is that the surgery team sometimes goes to other hospitals to operate on the donating body in order to obtain the organs. It’s called a procurement, and if a student is lucky, they’ll get to fly on a private jet to some far off destination to pick up an organ. On my final day of the transplant surgery rotation, we had a procurement. Unfortunately, it was only 20 minutes down the road at a local hospital, so no private jet was necessary. Nonetheless, I was looking forward to seeing what happens on the donation side of transplant surgery. By the time we got the call, the donor’s blood type was already matched, and the potential recipients already identified. The soon-to-be recipients of these organs had received the long awaited phone call at 5AM…“Your kidney is on the way, come to the hospital immediately for surgery.” The process of matching donors to recipients is a complicated one. It involves ranking potential recipients on a list based on their current health, then waiting for the right donor to come along that matches them well enough to actually serve as a donor. The process could take years. So, as you can imagine, it’s a special day when people find out they are finally getting their organ. So these patients started on their way that morning, some from four or more hours away, to get to the hospital for the operation, not having much time to think or prepare. And as these patients began their journey towards the hospital for long awaited organs, we began our road trip to the nearby hospital. The deceased donor turned out to be a drug addict who had overdosed on cocaine the night before and was now brain dead after having a large stroke. He had been kept on a breathing machine in order to make sure his organs were getting enough oxygen to keep them alive and functioning. His heart was still pumping blood. But the patient was very much dead.

The process of cutting out the donor’s organs began with a long incision all the way down his chest and abdomen. Our team was in charge of the abdominal organs (kidneys, liver, and pancreas), and another team would come in later for the heart and lungs. This order made sense, because taking out the heart and lungs first would leave the other organs without circulating blood and oxygen which could cause unnecessary damage. The process was slow…very slow. Each artery and vein had to be cut and tied off just right to ensure it could be placed properly into the new body. Four hours into the surgery, and we had yet to take out a single organ. It was just a lot of dissecting and clipping. At around the fifth hour, the heart/lung surgeon came in to check on our progress. But as he spoke with us, he noticed a small area on the lungs that looked funny, and asked us to take a quick biopsy (or piece of tissue) from the lung to have it looked at by a pathologist under a microscope. The tissue was sent away, and within 10 minutes, the pathologist came into the room and made the disappointing announcement.

“It’s a small cell.”

What that meant was this patient actually had cancer, a type of cancer known as small cell carcinoma. It doesn’t sound good, and it isn’t. This meant that we could not use any of the organs, because this cancer may have already spread to them. It would be truly unfortunate to accidentally give cancer to an organ recipient. Unfortunately, this meant we had just wasted four hours on a Saturday morning cutting open a human body for no reason at all. But this was nothing compared to what had to happen next.

Back at our hospital, two families were anxiously waiting. They had been called early that morning and told that today, they would get their long-awaited kidney. We walked into the private waiting room, and with a somber and compassionate look, the surgeon broke the bad news.

“Unfortunately, it turns out that the donor had cancer that no one knew about, so you won’t be getting that kidney today. So, go home, stay healthy, and chances are your name will come up again soon.”

A part of me was expecting these people to blow up…“HOW COULD YOU NOT KNOW THIS! I DROVE 4 HOURS AT 5AM THIS MORNING!!!” But the response was quite different. It was almost a sense of relief. I didn’t understand it at first, but it began making sense later. These people had suffered for years with their kidney failure, going for dialysis every other day, and at some point, it must have become a way of life. Sure a kidney would be great, but it would also mean a huge surgery. And that’s not all. Just because you get a kidney doesn’t mean you are cured. In fact, you are merely switching one disease for another, because after you get the new organ, you now have to take tons of drugs to weaken your immune system so that your body doesn’t reject the new organ. So, for the rest of their lives, organ recipients are “immuno-compromised”. Not an easy way to live, since you are much more likely to get sick. There was undoubtedly some disappointment mixed in with their relief, but in the end, I don’t think they minded waiting a bit longer.

Despite this difficult day, my transplant surgery experience overall was amazing. It was my first real appreciation of how far medicine has come, and the amazing things we are capable of doing. But it also taught me that medicine has its limitations. There is only so much we can do for those that suffer from afflictions like kidney failure, and unfortunately, there really is no “cure”, not even transplant. But as the years go by, more of these limitations will turn into opportunities to advance medicine. Who knows what is in store down the road – artificial kidneys made by the thousands in factories, a robotic arm for an amputee that actually moves when the patient thinks about moving it, small armies of molecule-sized drugs that go through your body and destroy only cancerous cells. It may surprise you that some of this is already in the works. It truly is an amazing time to be in medicine.

Chapter 8

Saying Goodbye

Ask the typical medical student why they went into medicine, and the answer is usually the same. It’s some variation of, “I want to help people.” What is often hard for us to realize early in our careers is that while we may be able to help many people and watch them walk out of the hospital, there are many others that aren’t as lucky. I learned this lesson very quickly one night during an eight hour emergency room shift.

I was scheduled to be in the ER for the night shift, which was from midnight to 8AM. It was usually a pretty good shift to work, as business tended to be the slowest at night. During my previous night shifts, I spent most of my time reading email. But this particular night would prove to be different. The first bit of excitement was an infant that arrived in cardiac arrest. The story was that the infant was found not breathing by her mother, and the ambulance crew had already performed CPR for 45 minutes before their arrival to the hospital without much luck. I kept my distance when the infant arrived, as over 15 medical team members, including pediatric residents, the emergency room attendings, and critical care nurses, all squeezed in to surround this tiny body. It appeared that this was a case of SIDS (sudden infant death syndrome) and the infant’s chances of survival were slim at best. But the team worked relentlessly, putting in IVs, performing chest compressions and administering drugs to get her little heart pumping again. Then, ten minutes into the resuscitation, two people with the most devastated looks on their faces came walking into the room – the child’s parents. The mother was frantic, and was yelling, “Please save my baby!” The father held his wife, and cried quietly. I had no idea parents or family members were allowed into the room during these resuscitations. The staff gave them a chair, and they were allowed to sit and watch as the medical team worked frantically. But despite the team’s efforts, the baby died. I can’t imagine what must have been going through the parents’ minds, and at the time truly wondered if having them in the room was good for either the parents or for the medical team trying to save the child.

Later in the course of the night came multiple trauma patients. One came in by helicopter from another hospital, and with him came some x-rays. He had been in a terrible car accident. I had the job of running the x-rays to the radiologist to find out what bones were broken while the rest of the team dealt with the patient. He had so many broken bones, I had to write them all down so I wouldn’t forget any when I relayed the message to the team. He survived long enough to make it out of the ER and into the intensive care unit.

The patients just kept on coming that night. As a medical student, we have the privilege of being able to walk into virtually any interesting case, and have the luxury of not really being responsible for anything, because everyone assumes that we know nothing. So, off I went into another interesting case. It was an 81 year old man who was found unconscious by his family. But as EMS rolled him into the room, he was sitting up and attempting to communicate. Unfortunately, he only spoke Greek, so we were unsure of what he was saying. He looked extremely frightened, and in the middle of his sentence, stopped speaking, and slumped over unconscious. The team immediately began the resuscitation. His clothes were stripped off, IVs were placed, and medications were given. EKG leads were stuck onto his chest, and a needle was placed through his chest and next to his heart in an attempt to drain fluid that was thought to be building up. A tube was placed down his throat to help him breath. Two lines were placed in his femoral arteries very close to his groin. Chest compressions were started, and after a few minutes, the emergency room physician looked over at me, and calmly said, “You ready?” He wanted me to do chest compressions! I was, in fact, ready. Finally, a chance to actually help out. So, I stepped onto a small stool next to the stretcher, leaned over the body, and began pressing my body weight into this frail man’s chest, fearing I would soon feel ribs popping under my hands. Mercifully, I did not. This continued for at least ten minutes before I heard the dreaded words… “The family is here, they would like to come in.” Here I was, beating on an old man, a naked man that had tubes coming out of everywhere, and they were going to let the family see this?! And indeed, there they were, the wife, and the son. The wife was obviously distressed, and she immediately walked to the head of the bed amidst the chaos and sat beside him, crying, stroking his face, talking to him in Greek. She seemed to be oblivious to the lines and tubes, she saw only him. I looked at the attending, hoping to get the sign to stop, and he did indeed tell me it was okay to stop. He turned to the wife and put his hand on her small shoulder.

“I’m sorry, we’ve lost him.”

We eventually left the room, and allowed her to be alone with her husband.

In the course of 8 hours that night, four of our patients had died. It was more death than I had ever thought I would see. I dealt with it better than expected, not letting it truly bother me until my drive home, when I began thinking of all the people that had lost their loved ones that night. A mother had lost her child. A wife had lost her husband of over 50 years. That’s when it hurt. I sat and thought about how the families had the chance to be with their loved ones during their final minutes of life. Although I had my doubts at first, the elderly couple convinced me that this was the right thing to do. She got a chance to be with her husband and say her final goodbye during his last moments. And although our fancy cardiac monitors would have us believe he had probably passed away before she even came into the room, something in me believes he heard her say goodbye.

In the end, it seems like what people need most is some sort of closure. Although terrifying, letting family bear witness allows them to realize that everything possible was done for their loved one. But more importantly, it gives them a chance to say goodbye. I can’t imagine denying anyone that chance.

Chapter 9

The Reoccurring Refrigerator Incident

Exposing students to actual patients is something most medical schools try to do as early as possible. These early encounters allow students to develop a sense of comfort in what can often be an unsettling environment. After all, we as students are probing into the health problems of patients, as well as examining their bodies, two very personal matters for a patient. So, it makes sense to get students out there early, and allow them to get adjusted to this new environment.

During the first semester of medical school, we spent a small amount of time each week in a course designed to teach us the intangibles of the patient-doctor interaction…how to talk with patients, how to give bad news, and how to be compassionate caregivers. They even hired local actors who played the role of fake patients and allowed us to interview them for practice. When the second half of our first year came around, we were finally allowed to see the doctor-patient relationship in action by shadowing a physician in clinic. I was paired with a family medicine doctor. Looking back, it’s obvious that my view of medicine at the time was the “bright-eyed and bushy-tailed” version where doctors were always compassionate and caring, and addressed each patient’s problems with enthusiasm. As the day started, it was living up to this, as the doctor saw only a few patients and was able to spend the time to address even their minor issues. As we got midway through the afternoon, we stepped out of a patient room, only to be confronted by a frantic nurse. The patient in the next room was seizing. The doctor, unphased, slowly made his way to the room. We entered together, and sure enough, there was a woman in the corner, sitting in her chair, making jerking movements of all her extremities, appearing to be unresponsive, while her sister stood beside her, trying to comfort her. The doctor looked at them for about one second, then went and calmly sat in the opposite corner and started looking over her file. I was in disbelief. “Shouldn’t you do something?” I thought to myself. Why didn’t he care? This woman was in obvious distress. Eventually, the seizure stopped, and her sister sat down and began discussing how these episodes happen multiple times each day. The doctor, still busy reading the file, didn’t even look up, so the woman directed most of her comments at me. I was obviously concerned for them and listened attentively and she picked up on this. Finally, the doctor began talking, cutting her off mid-sentence…

“So what do you want?”

There was no compassion in his voice, but a cold, matter-of-factness that made me uncomfortable to be in the room.

“Well, we’re out of her pain medication, and she needs more. She’s in so much pain.”

“Did you go to the pain clinic like I asked you to?”

Again, the doctor’s voice was cutting, and now bordering on accusatory. I couldn’t believe what I was hearing. This woman was obviously suffering, her sister was trying to help, and here was a doctor who apparently didn’t care.

“No, we never had a chance, but we’re planning on going there next week.”

The woman seemed very genuine, and her sister was looking much better following her seizure, and began participating in the conversation as well.

“Yes, I’m definitely going to go as soon as I can find some time. But I just need some medication until I can get there.”

With this, the doctor abruptly got up, and headed for the door.

“Let me see what I can do.”

We both left the room and went back to his office. I wanted to stand up for this patient. I wanted to yell at the doctor, “Why are you treating them like this?! This patient needs you!” Where was the compassion I had heard so much about? But before I had a chance to question what I had just seen, the doctor said the two words that would slap the bright-eyed picture of medicine out of my system forever…

“She’s faking.”

Just having started medical school, I did not yet have the knowledge to appreciate a medical con artist at work. But anyone with medical training would have seen this patient and realized that all was not as it seemed. For example, true full-blown seizures, such as this woman was apparently having, are followed by long periods of excessive fatigue or sleep, and the patients never return to normal right after the event. Second, generalized seizures lead to loss of consciousness, making it nearly impossible for them to actually stay seated in a chair during the event. And lastly, and perhaps most importantly, pain medication is not a treatment for seizures, so asking for pain medication to prevent a patient’s convulsions screams, “I’m a drug addict” to any doctor.

“They come here all the time,” the physician continued, “always asking for pain medications. They’re both abusing it. The sister has a known history of drug abuse. Those aren’t seizures you saw. It’s all an act.”

The very next year, while spending a month working on the inpatient neurology service, the attending asked that I go evaluate a new patient whom they suspected had pseudoseizures. This phenomenon occurs when a patient appears to be having a seizure, but when hooked up to electrodes on their heads, the firing of neurons that are present with real seizures is not present. These events are usually triggered by stressful situations, and often come along with a history of prior abuse. No one is quite sure whether patients intentionally have pseudoseizures. Most believe that even though they aren’t a result of true organic pathology, in a way, it is still out of the patient’s control. It is the body’s unconscious way of dealing with a stressor, similar to having a headache when we are stressed. This particular patient had recently revealed to his family that he was gay, and it had not gone over well. While at work, he had an apparent seizure. So, I went in to examine the patient, and as we were talking, he went into a spell, with arms thrashing all over the place and hips thrusting off the bed. By this point I had seen true seizures, and I knew this wasn’t it. He was already hooked up to electrodes to determine if he really was having seizures, and to no surprise, there was no increase in firing from his brain, leading to the diagnosis of pseudoseizures. He was discharged that afternoon, with an appointment to see a psychiatrist.

By the time I was a fourth year, I had all but forgotten these two incidents, and once again began taking things at face value. That was until I started my emergency medicine rotation.

The emergency department is an interesting place. There are those that come in with real problems, such as chest pain and lacerations in need of stitches. But the vast majority fit under the non-acute category. These are the people that come in with issues that belong in their regular doctor’s office, such as rashes, ear aches, diarrhea, and even trouble sleeping. These are not emergencies. And finally, there are those people that do not belong in any medical facility. These are the most frustrating to deal with.

It was getting late in the evening when a new patient’s name popped up on our computer system indicating he needed to be evaluated. Under the reason for visit, it read, “back injury”. I found him outside in the hallway (all of the other rooms were full), waiting on a stretcher. He was in obvious discomfort. He could barely lift his hand to shake mine as I introduced myself.

“What brings you in here today?”

He winced as he replied, “I’ve hurt my back. I was helping my son lift a refrigerator and heard a pop in my back, and it’s been killing me ever since.”

I asked him the various questions that might indicate he herniated a disc.

“Do you feel pain down your leg?”

“Yeh, it feels like lightning shooting all the way down. I can barely move.”

“Any trouble using the bathroom or numbness in your thighs?”

“No, just can’t move, I’m in so much pain.”

I examined him, lifting each leg and watching him as he writhed around in pain.

“Have you ever hurt your back like this before?”

“No, I’ve had some back pain from a car accident, but this is different. Never hurt it like this.”

And then came the line that every ER physician hates to hear:

“I think I’m going to need some vicodin. I’m allergic to almost everything else. It’s the only thing that works for my pain.”

This man had all the signs of a drug seeker. He knew the name of what he wanted, he knew exactly how to describe his back pain without prompting us to do further testing like an MRI, he was “allergic” to everything else, and he had a good story. Being somewhat naïve, I bought his story, and went back to the attending doctor to tell him of my findings, convinced this man needed some strong pain medications. I began telling my story to the doctor, but before I could finish, he had pulled up an ER report from the same patient a year earlier. The report read, “Patient presents with back pain after lifting his refrigerator earlier today…” I had been duped.

Patients who are addicted to pain medicine end up going from doctor to doctor with their story in hopes of scoring narcotics. Once the doctor is on to them and stops prescribing medicine or tries referring them to pain clinics for further help, the patient disappears, and ends up at another doctor’s office. It’s a very sad thing. This patient was undoubtedly going from ER to ER with his story, hoping someone would buy it. He probably forgot he had already used the story at our ER, or maybe he didn’t know we kept electronic records.

As we walked back together to see the patient, the competitor in me was hoping the attending would tell him he had lost in his attempt to trick us, and that he should not go to ERs because it was a huge waste of taxpayer money and everyone’s time. But he simply went up to him, said we could give him one dose of medicine since he was in the ER, but that he needed to go to his regular doctor for a prescription. He was an experienced ER doctor, one could even say he was a bit jaded, because he knew there was no need to waste his breath or any more of his time. No matter what he said, this man would just simply go somewhere else and try again. Such is the way of addiction. So, no, we did not win this battle. In fact, we were all losers, in one way or another.

The patient figured his scheme was not working, and did not make any argument. The nurse brought him his medicine, and I went back to let him know he was free to go. As I left him to go see my next patient, I looked back in time to catch a glimpse of him walking comfortably out the door.

I learned a great deal from these three patients. First, I learned to be a bit more critical of patients, a lesson I wish I had not learned. Second, I learned that problems you can’t simply fix with medicines are harder to treat, and often more disabling for patients. Finally, I learned that there comes a time in every medical student’s life when they realize medicine is not quite what they had imagined. For me, no longer was medicine always about the grateful patient, the dedicated doctor, and the disease we would fight together.