Tuesday, February 28, 2006

widen your circle of compassion

I had a very disturbing interaction with a subspecialist yesterday. It was my last morning on the ward for the month and I had just signed out all my patients to the new team. I get a page from this specialist about a consult I had ordered the day before. I called him back and the exchange went something like this (identifying details changed to spare the innocent):
"So, what can we help you with?"
"Well, he is an 18yo with end-stage lung disease and we were wondering if he had cor pulmonale."
"Well, how would that change his management if he were?"
"We might encourage him to wear oxygen more frequently if we knew that he was in failure."
"Does he wear oxygen now?"
"Well, yes, but not all the time. Only when he feels short of breath."
"It's a little late for compliance, isn't it?"
[an awkward pause, as I'm not sure how to respond. Finally, I say:]
"Well, we'd like you to see him and possibly get an ECHO."
"I'm just not sure what that would accomplish. Essentially, he's dying and you don't have a cure for him!"
As I reflect on this conversation, I am struck over and over by this man's callousness. In our particular institution, you have to get a cardiology consult to get an ECHO. That's not true in other institutions. Due to that peculiarity, they've developed a sense of superiority that enables them to question without impunity other specialists. Basically, a power trip.
This is a patient who IS dying. We don't have a cure for him, but that doesn't mean that we don't owe it to him to make him as comfortable as possible during the time he has left. We need to find out if he is in heart failure due to his lung disease. We need to revise our management based on that knowledge. This boy has had a hard life, beyond what most people can or should fathom. He deserves to have an easy death, to slip quietly away in his sleep without pain or worry.
We owe him our compassion.
We owe him our diligence and perseverence in finding treatments to help him.
We owe him a god damn ECHO.
In the end, I told the consultant with the sensitivity of a doorknob that my attending would love to have this conversation with him.
I am reminded of a quote from Albert Einstein..."widen your circle of compassion."

Sunday, February 26, 2006


A short preamble...
During my 8 months as an intern, there have not been an overwhelming opportunity to do procedures. My first month in the ICN, I had 3 opportunities to intubate one of the little wee ones. My record was 1 for 3. Not the best. Also not all that confidence-inspiring, considering that next year, as a 2nd year resident, I will be on call without the back-up that I've had this year. During my second month in the ICN, I had NO opportunity to intubate. None. Zero. So, needless to say, I was a bit apprehensive about my looming role as a 2nd year.
I was happily minding my own business this afternoon over on the ward when the nepnatal nurse practitioner calls over and asks if I want to intubate one of the babies in, say, 20 minutes? Sure, why not. I'm 1 for 3. I'll either be 1 for 4 or 2 for 4 after it's all said and done, right?
Several, deep, calming breaths. I can do this.
I am now 2 for 4.
It went fairly quickly, although I think I initially intubated his right mainstem in my zealousness to get the tube in the right hole. Just pulled it back a smidge and, voila! Equal breath sounds on both sides. If only they were all that easy...