In case you are wondering, the all-star Monday morning quarterback is me. I’m not good at Monday morning quarterbacking everything, but I do have my specialties: relationships, child-rearing, life decisions in general, finance, and other people’s patients. I’m awesome at any of those categories.
The more removed from the situation, the better I get. My own patients? They’re complicated little balls of nuance that may take me days to sort out. The med student’s patients? They’ve got a lot going on but more manageable for sure. My APP’s patients have their snags but I can untangle them without too much trouble. A different attending’s patients? Piece of cake. A different attending’s APP’s patients? Puh-leeze!
Similarly, it’s hard to know in the moment what the optimal thing to do is when the kid I’m babysitting wants to sleep and it’s not their designated nap time. But if you are narrating your sleep training woes to me I can tell you exactly where you’re going wrong. (Maybe let’s start with the idea that you need to train your baby to sleep.) Does it matter that I’ve never parented a child? No, all that experience would just muddy the waters.
Moral of the story, if you need help with your complicated patients, relationship questions, or parenting conundrums, look no further. I’ve got your back.
SDG
P.S. I hope it goes without saying that I do not actually believe any of the above is true… although admittedly I act like it sometimes.
When it is a relatively busy or steady shift at work, I’m happy to take on another task. Bring it on!
When it’s a slow day at work, by the end of the day I don’t want to do anything. Sitting on my hands for three hours and then having to take an admission? Agony!
On the other hand, if things are busy enough to be chaotic and the workload keeps piling up, I start getting overwhelmed. Fortunately, there are enough people scheduled each shift and the past load is such that I’m rarely in that position.
In terms of job satisfaction, slow day at work < hectic day at work < pleasantly busy day at work.
Similarly, if I have a relatively busy day, I am also likely to get my email cleared out as well as the few extra bonus tasks that have been on my to-do list. If it’s a slow day at work, at the end of the day I’ll realize I forgot to do a few required things. It’s curious.
Anytime I admit you to the hospital, I have to ask you about code status. In other words, if your heart stops beating, do you want us to try to start it again? (The process of attempting to do so is called cardiopulmonary resuscitation, or CPR.) If you are unable to successfully breathe on your own, do you want us to put a tube down your throat so a machine can breathe for you? (This is mechanical ventilation.) If you want both, that means you are “Full Code.” If you would not want CPR but would want to be on a ventilator, then you are DNR (Do Not Resuscitate). If you don’t want either, you are DNR/DNI (Do No Resuscitate, Do Not Intubate). If you want CPR but not intubation, too bad, you can’t do that. When your heart stops beating you also stop breathing, so you have to be ok with getting both.
On the regular, I will ask someone this question and they will answer, “I’d like you to try to revive me, but if it looks like I’m going to be a vegetable then stop.”
My answer: We can’t know if you are going to be a vegetable.
(It goes without saying: you will never be a vegetable. We are mammals. Nothing medical science can do will ever turn you into an edible plant.)
There is the question, what do they mean by vegetable. I think they usually mean, permanently unconscious: brain dead. Well, guess what. As doctors, even with the best tests we can’t generally say that 100%. There is a surprising amount of controversy in this area. I don’t think most people realize it is so gray.
But more importantly, we aren’t God. If you heart stops, we have no idea what is going to happen when we start chest compressions, electric shocks and IV medication pushes. We can guess what we think is going to happen, but I’m pretty bad at that. Maybe you are just going to die. Maybe you will wake up in a minute and talk to us. Maybe we are going to pound on your chest for forty minutes and then you will be unconscious and on a ventilator in the ICU and maybe you will wake up in a few days or maybe not, and maybe if you wake up you won’t be able to move the right half of your body. Saying you want to be “Full Code” means you have to be ok with all of those options, you can’t just choose the good one.
You know what I want your answer to be? If you are a healthy person over the age of 85, I want you to be DNR/DNI. If you are an unhealthy person over the age of 65, I want you to be DNR/DNI. If you are a really unhealthy person over the age of 40, I want you to be DNR/DNI. (Exception being if you are in surgery. Most people, even if they are DNR/DNI, will transition to Full Code during surgery, because it is so successful in this situation.)
Why? Do I hate people? Do I want to take care of fewer patients?
Admittedly, it’s probably bias. I haven’t seen that much CPR, actually. But the CPR I’ve seen has not been pretty. It has been brutal. And it has been mostly unsuccessful. Do you want the last minutes of your life to involve someone pounding on your chest, breaking your ribs, shoving a tube down your trachea, shocking your chest?
Doctors, advanced practitioners, nurses and other healthcare providers go into medicine because we want to help people. Oftentimes CPR feels like we’re doing the opposite.
I, as a healthy person in my mid-thirties, want CPR. I would want my husband, my siblings and my mom to have CPR. I’m not against it. It’s just not for everyone.
Everyone should have advance directives. Advance directives specify what kind of medical care you would want in the event you are unable to express a decision. Ideally, these should be written down, along with your designation for medical power of attorney (POA) – the person who would make decisions on your behalf if you can’t make them yourself. If you don’t want your closest relative (spouse, child or parent) to make decisions for you, then a document naming medical POA is essential.
Perhaps just as important is talking with the person who would be your medical POA so they know what you would want. Ideally, if your medical POA is making decisions on your behalf, it should feel relatively easy for them because they already know what you want – they are just relaying the message to the medical team.
Advance directives usually have a question about code status, about what you would want if you were expected to be permanently unconscious, or have an incurable and rapidly progressive medical condition that will result in death. Usually they ask if you would want tube feeding for nutrition if you can’t eat. They might ask how you would like your pain controlled, and if you want your organs donated if possible.
One thing to note is that as humans, we aren’t the best at predicting what we will or won’t be ok with in the future. There is a principle called hedonic adaption that says that we tend to get used to nice things pretty quickly. For instance, in medical school I had the Lasik procedure. In the days that followed (after the sand-in-the-eye feeling went away), it was amazing! No need to put on glasses or deal with contacts! Everything clear! But pretty quickly it became normal.
Now, maybe every few months I remember that my eyes didn’t used to see 20/20 and I feel a wave of gratitude, and yes, the irritation of dealing with foggy lenses or a misplaced contact doesn’t happen any more, but I can’t say that I’m particularly happier than I was before I got Lasik. My body got upgraded, and my expectations upgraded as well.
Fortunately, the same thing can happen when our bodies downgrade. Studies show that people are able to adapt to their misfortunes. Again, I’ve experienced some of this myself. With my current hip problems, I can’t go on a casual walk or participate in a lot of fun activities. This has definitely been frustrating and life-altering and I know I’m missing out on things, but am I sad about this all the time? Nope. I don’t think my happiness level is hugely different. If I was miraculously healed and back to my “normal” self, I could see myself being a lot happier – for a week or two, maybe a month. At that point I suspect I would have adapted to my new reality.
Generously, one in three people who undergo cardiopulmonary resuscitation (CPR) in the hospital will survive. (Success rates are lower outside the hospital.) Congrats, that’s what you were hoping for! CPR does have side effects, however… but you only experience the side effects if it successful aka you are still alive.
Broken ribs. This is the most classic side effect. The older you are, the more likely this is going to happen, because ribs get more brittle with age. If you are a little old lady, your ribs are going to snap like toothpicks. What do broken ribs feel like? As far as I can tell, nothing good. Breathing will be painful, so the temptation is to take little tiny breaths instead of big ones and to avoid coughing at all costs. Unfortunately, doing this sets you up for pneumonia, which you are already at increased risk for being in the hospital. So we’re going to be asking you to take those big, deep, painful breaths anyway. You may need to go on opioid pain medication in order to do so, which comes with its own litany of side effects (like constipation, confusion, and dependence).
Brain damage. About one third of people who survive CPR will have brain damage. This does not mean you are an unconscious “vegetable.” But maybe you are. Or maybe you just can’t live by yourself anymore because it’s too unsafe.
Trachea/vocal cord damage. If CPR goes on for more than a few minutes, we are going to try to place a breathing tube. In the process, the tube may injure your throat, including the vocal cords. Swallowing may be painful for about a week. Your voice may never be the same.
More time in the hospital. No one comes out of CPR healthier than when they went in. You will likely end up in the intensive care unit for close monitoring, which is going to involve more tests, blood work, and interruptions. Almost certainly your hospital stay will be prolonged. Longer stays in the hospital mean greater chances for other things to go wrong.
More likely to not go home. You’ll be weaker and may need to spend time rehabilitating in a nursing home. If you are fortunate, you will rehab back to home or move into an assisted living where you have more support. If you’re less fortunate, you’ll be a permanent nursing home resident.
More likely to return to the hospital. Generally, hearts don’t just stop beating out of nowhere. You probably have some serious medical conditions that are not going to go away. You may also have more health problems as side effects of CPR. (See above.) As a result, don’t be surprised if you continue to get ill enough to require repeated hospitalization. Your doctors certainly won’t be.
More likely to die. A study examining CPR in older adults with medical problems like heart failure, COPD, cirrhosis and cancer found more than half of them were dead in 6 months.
Again, you only get these side effects if CPR is successful: the alternative is being dead. The older, sicker and more frail you become, the more likely you will experience these side effects and the more severe the side effects are likely to be. You will also be less likely to survive to experience them.
In general, if you are under sixty, I’d say it’s worth doing. (That recommendation would change if you have metastatic cancer or other severe health problems.) Over sixty becomes more gray as people accumulate more health problems. Ultimately, the decision is up to you, but it’s important to know what your decision means.
I enjoy reading articles with titles like, “Advice I would have given my younger self.” Often some of the advice has to do with avoiding mistakes or heartaches that happened along the way. Well, I have experience with some of those!
I could have avoided a five-year detour into dietetics if I had the confidence to stay pre-med in college.
I could have skipped over two boyfriends and some awkward and painful moments that resulted.
I could have avoided a year of long-distance dating.
I could have gone straight into Internal Medicine and skipped many painful experiences in clinic + started making an attending salary a year early.
If I know anything from time travel stories, however, it’s that my life would be a lot different if those things hadn’t happened. Would I even be a doctor? Would I have any of the friends I’ve made in the last fifteen years? Would I be married to my husband? Would we have had Lindy? This year I’ve gone on two road trips and attending two weddings that wouldn’t have happened if I hadn’t become a dietitian and ended up in Yankton, South Dakota. Thank God it was so. Not every instance is so clear, but it’s reassuring to look back at mistakes I’ve made and see how God has used them to bring good things into my life.
Things I DO regret?
Giving away my apple peeler corer slicer. At the time, the convenience didn’t seem worth the imperfections in the final product. How wrong I was.
Singing a classical Latin piece for the final show choir concert, instead of a crowd-pleaser. Ah, the hubris of youth.
Allowing Birdie to keep me company at the table when we were living alone together. She was already a trash panda but if anything this cemented the behavior. Unwatched plates will never be safe.
As a patient, you do not want to be “interesting.” Being interesting typically means your symptoms are not coalescing into a standard diagnosis or for unknown reasons you are having an atypical response to things that normally work. It means as healthcare workers, we’re not sure what to do with you.
This is one of my most unfavorite things as a provider: not knowing what is going on with one of my patients. Frankly, it makes me grumpy. I’m not as nice to these patients, not because I don’t like them, but because I get frustrated. Getting to a diagnosis, even if it reveals that I was not being as smart of a clinician as I should have been earlier on, is a relief.
I am in the unfortunate situation of being an interesting patient myself. This afternoon I had an appointment with yet another specialist. I had a few goals for the visit, but mostly I was content that this would check another box off the long list of things I have or haven’t tried yet.
My appointment started twenty minutes late, and ran twenty minutes over, with a long wait in the middle. The specialists I saw do not know what is causing my problem, and they don’t know what is going to make it better.
And yet, I left the appointment feeling better about the trajectory of my care than I have for a long time. I felt hopeful, and grateful.
How? Why?
One observation is that the doctors, while acknowledging that they didn’t have a great idea of what is going on, didn’t toss me out like a hot potato. Instead, they expressed an interest in trying to figure it outwith me. They discussed the pros and cons of trying medications and therapies that, frankly, they have no idea will work or not, but should be safe to try. They encouraged me to try them, and are willing to do their part in facilitating what they can.
Another observation is that they utilized their connections on my behalf. The fellow and attending physician talked with a colleague who has more experience in the area that my ailment involves, and she joined us in the exam room to tell me her thoughts in person. She offered to discuss my case further with a colleague in a different specialty, as well as to reach out to someone she knows at Mayo Clinic for their opinion.
All of this felt like a giant relief. Up until now I’ve felt like I’ve been the one directing my care, asking to see this specialist then that one, suggesting one diagnosis and then another, asking about specific treatments, not knowing what I was doing. It feels like I’m now seeing people who, if they don’t know what they’re doing, know people who might – and they plan to follow up. It feels like they are going to keep trying things with me as long as they can come up with things to try.
To be clear, none of the other healthcare providers I’ve seen have done a bad job, but none of them seemed interested in taking ownership of the problem or being directive with next steps. And, it may just be that I finally found the specialty that I should have gone to in the first place, and the reason the providers are being so helpful is that they are truly the only ones who can help.
Being Mortal: Medicine and What Matters in the End by Atul Gawande
Mr. Gawande is an excellent writer. He’s the kind of writer who writes stories, and then weaves them into the point he’s trying to make. (Morgan Housel does that, too). This helps make Being Mortal a fast read, but it has spots worth slowing down for. In short, this is a thoughtful book and I think most people would benefit from reading it and then discussing it with loved ones.
Being Mortal is concerned with what happens to us at the end of our lives: specially, what happens to us in the medical system. Modern medicine allows us to keep people with serious illnesses alive far longer than at any other time in human history. Unfortunately, this can lead to hard decisions and high costs, and it’s not clear that our medical interventions make people’s final years better.
I witnessed this with an older relative. She fell at home, and later the doctor found a large deep tissue injury that was infected and required surgery. With the hope it would heal, she had another surgery, experiencing delirium in the hospital. She then had a stay in a nursing facility, where she received (at times) substandard care and had a wound management system applied incorrectly, ultimately leading to another infection that required re-hospitalization, another surgery and more delirium. By this point my husband’s parents had enough and took her home, but the surgeon still held out hope she would heal, even as she wasn’t eating. She had an expensive and resource-intensive wound vac in place for weeks before transitioning to hospice.
While the book doesn’t offer any easy answers, it does suggest some questions that should be considered when someone has a serious illness.
What do they understand about their illness and their prognosis?
What are their concerns about what lies ahead?
What kind of trade-offs are they willing to make? What trade-offs are they not willing to make?
How do they want to spend their time if their health worsens and time is short? What are their goals?
Who do they want to make decisions if they can’t?
One of the physicians in the book phrases it another way: “How much are you willing to go through to have a shot at being alive and what level of being alive is tolerable to you?”
Honestly, these are not bad questions to ask before someone becomes seriously ill. They are not bad questions to ask yourself and discuss answers with trusted loved ones. Catastrophic things can and do happen to healthy, active people at unexpected times and with little warning – I see it regularly in the hospital. Having a healthcare provider assist in this discussion would probably be helpful (especially to make sure #1 is accurate), but I don’t think it’s essential. If you have a firm grasp on the answers to these questions, even if you don’t have the answers to nitty gritty medical questions, your healthcare team should be able to help apply them if you make goals/hopes/wishes clear.
One thing that felt prescient was Mr. Gawande’s discussion of medically-assisted suicide. He doesn’t outright condemn the practice, but worries that it essentially provides a way for people to ignore caring for the dying – you don’t need to, because if things are too bothersome they can just end things immediately. He notes that “the fact that, by 2012, one in thirty-five Dutch people sought assisted suicide at their death is not a measure of success [but] failure,” and links it to inadequate hospice programs. If people have access to resources that will help reduce suffering and improve their lives in their final days, he argues, they won’t choose to cut them short.
Unfortunately, this is what is happening in Canada. Canada legalized medically-assisted suicide, or “MAID” (medical assistance in dying) in 2016, two years after Being Mortal was published. It is also known to have inadequate social supports and hospice resources. Today, one in twenty Canadians dies from medically-assisted suicide. Despite this evidence of failure, people instead seem to be interpreting it as evidence of its success. Proponents are moving forward with the goal of expanding MAID eligibility to people who have chronic mental illness. Cynically, I wonder if more people choosing to die saves the healthcare system dollars.
One thing this book lacks is a Christian perspective. Mr. Gawande is areligious. While I still think this book provides a lot of wisdom and things to think about, faith plays a role in our final days that we must acknowledge and can also make a big difference in our perspective of things.
It’s one of those facts that gets brought up to illustrate how people don’t think rationally: way more than 50% of the population believes they are above average drivers. I think it is something like 90%. (Don’t quote me on that.)
Now, you could argue terms. What do we mean by average? Are we referring to the median, which in this scenario would be found by lining up all the drivers in order of worst to best driving ability and picking the person who is exactly in the middle? Or, are we referring to the mean, which would be found by somehow adding up the driving ability “scores” of all drivers, dividing it by the total number of drivers and designating everyone above that number as “above average”?
It matters, because when you use the median as your average, by definition half of the population will be below the median and half will be above it. That’s how the first paragraph builds its case. When you use the mean as your average, however, it would actually be possible for more than 50% of the population to be above average, if the below average drivers were just really bad. As an example, say there are ten students taking a test. Nine get 100% on the exam and one unlucky bloke slept through it and gets 0%. The mean grade would be 90% (add up all the scores, 100 + 100 + 100 + 100 + 100 + 100 + 100 + 100 + 100 + 0 = 900, and then divide the total number by the number of students, 900 / 9 = 90), so nine of the students would be “above average” and just one would be “below average” if by average we are referring to “mean.” The median would be 100% so ironically no one would be above average using that definition, although one student would be below average.
Using the median definition of average, I feel quite confident in saying I am a below average driver, and half of the people reading this (zero?) should feel comfortable admitting to the same. Anecdotally this makes sense to me. Considering the drivers in my family, I am definitely in the bottom half of skill level. To be clear, I don’t think I’m a bad driver, per se, although that could be argued. (The fender bender I got into this morning was not a confidence booster.) But wouldn’t you hope that more than 50% of our drivers are good ones?
On the other hand, if we use the mean definition of average, I’d be a little more uncertain about where I fall. There are some seriously bad drivers out there that would skew the mean downward, and I think it would be hard to be so outstanding at driving that you would meaningfully pull the mean upward. Perhaps I’d be able to squeak in “above average,” but if so more than half of all drivers would be with me.
By the time this is posted, it will be past that time of the month, but as it is… right now I’m in it.
The last one or two or three days of my menstrual cycle. Wondering if, this time, maybe I won’t get it. Telling myself not to hope for that because the next time I go to the bathroom there will more likely than not be a rust stain on my underwear. Feeling a tickle and wondering if it’s blood or just routine cervical fluid. Debating whether to keep sitting on the couch or to walk to the bathroom to check. Feeling a stupid sense of relief when there’s nothing there, and immediately chastising the feeling. Feeling the tickle again when I sit back down and resisting the urge to return to the bathroom. Checking my period-tracking app again to see if it’s too early to think about buying a pregnancy test. Six dollars for either an abrupt I told you so and resigned waiting for the inevitable red gush or a lottery ticket to keep hoping on. Deciding it’s worth it. Preparing for the hope bubble to swell in the next few hours until it’s burst with a single blue line. That won’t stop my heart from beating faster while I wait for the designated two minutes.
Where is God in all this? With me, I guess. He hears my worry and sees my restlessness. He knows if I’m getting my period in the next minute, in one day, in one week, or in nine months. He knows if I will get pregnant again or if I will go on, month after month, with a regular cycle of blood.
