Requesting Direction

[GWD]

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So, I had one of my monkeys die this morning.

I treated it last night, and I was the last one to see him alive.

It was one of the most devasting, sad, and pathetic things I have ever seen.

I knew he was dying, and I just stood there and watched him for about 15 minutes, and for the first time in a long time, I wept.

It was a difficult thing to deal with, since I empathized not only with our relationship-lost, but the terrible suffering he was undergoing.

So this questions goes out to all of us... those of us in training, those of us aspiring, and those of us practicing...

How do you set aside those emotions?

I have known for years that I could never do peids, or peids onc... I just know that I don't have the emotional wear-with-all to be able to handle those types of things.

This has really caused me to call into question if I have the thick-skin to deal with this sort of ****. This was just an animal... how is it going to feel when I lose a human patient?

So anyway.. just rambling... God Bless those with the inner courage to deal with this ****... I hope I can someday summon it too

 

[gbwillner]

You don't really have to set aside your emotions. After it happens a few times you start to realize it's just part of life and your job... and you kind of get numb to it. The hard part for me is always speaking to the family afterwards, because it's hard NOT to get caught up in the emotions they bring out.

 

[GWD]

Well.. I've always thought that my passion aids me in my calling and committment to do what I do.

No doubt these aspects of the job just ****ing suck though.

"Numb" is a scary concept. It leeches from the idyllism of passion and compassion, but I guess it is also a necessary part of being able to focus on the other aspects of life, such as love, happiness, and being able to sleep at night.

This is a strange balance, and this is a weird career. I just humble myself and ask for the strength to do what at times seems like such a difficult thing to do.

 

[GWD]

Btw, I appreciate your insight and guidance on this issue gbw...

I suppose this is the Physician's Dilemna

I hope these feelings never become less real to me, but at the same time it is a feeling I abhor continuing to face as a part of my job

The way I've always dealt with it in the past is just to think that it is GOING TO HAPPEN, so I must devote myself to making sure that there is the most well-qualified person I can be in place when it does

 

[gbwillner]

Btw, I appreciate your insight and guidance on this issue gbw...

I suppose this is the Physician's Dilemna

I hope these feelings never become less real to me, but at the same time it is a feeling I abhor continuing to face as a part of my job

The way I've always dealt with it in the past is just to think that it is GOING TO HAPPEN, so I must devote myself to making sure that there is the most well-qualified person I can be in place when it does

Nothing is really ever as it seems when we first start out. We all want to be sympathetic and compassionate for our patients, and its something that you have to TRY for later on, as things become more monotonous.

As an example, I find that many people who go into IM tend to hate patients after 3 years. Service goes from wanting to save the world to "How quickly can I stabilize the patient and send them home" to "Let's make everyone DNI/DNR" to having hospice care numbers memorized. For many the cases themselves become interesting, more so than the people. It's a job, and like any other things get repetitive and no longer affect you like they once did. I am a pathologist, and the first autopsy I did was hard. I wanted to answer all the questions and be extremely meticulous and careful. After 20 I just wanted to finish the evisceration as quickly as possible.

I think the numbness is good. If you freaked out every time your patient died you'd never make it through internship year.

 

[Ariodant]

If everyone turns away because they can't handle the emotions, who's gonna treat those patients? Stop witnessing death doesn't stop it from happening, in fact, to everyone one of us.

 

[Doodledog]

Much of this comes with experience. Almost everyone is upset and many cry when they have the first (few) experiences of having a patient they cared for die. This tends to be more common in residency than medical school since often the resident has gotten to know more patients and is handling sicker patients.

What makes this get better is that with experience you know what death "looks like", how families handle it, and most of all you've learned what to say and what not to say. You'll learn that you have a "role" to play (pronouncing the patient, DNR orders, autopsy consent, etc may be tasks you'll do) and that helps in giving one a reason for being around. In addition, with time, you'll learn that staying around as much as possible is comforting both the person who is dying and the family. No one wants to be abandoned in their worst or last hour and neither do families wish their doctors to abandon their loved ones, even with they realize nothing more can or should be done. The families (and the patients) may not always be able to express appreciation at that time, but it is there.

Venting to friends, on and off line isn't a bad coping mechanism either.

 

[strangeglove]

An important difference between a monkey and a human is that you can talk to a human. Being there to talk to someone who is dying and by doing so actually making death more dignified is one of the more satisfying aspects of medicine. It's one of the most effective and important interventions at the end of life, much more so than intubation, pressors and the like.

 

[QofQuimica]

Personally, I don't think there is anything wrong with being emotional about a death, especially if it was a patient (or even a monkey!) you were close to. As a student, *you* often are the one who spends the most time with the patient because you have the most time of anyone on the team. So unsurprisingly, you become close to some of them.

What makes a patient's death the hardest on the family (and you as well) is when the death is unexpected. It's one thing if a patient is terminally ill and they and you know that their death is inevitable. Then everyone has time to prepare mentally. I've had a couple of patients like this who had reached a point where there was nothing more that could be done for them beyond making them comfortable. I'd go visit them just to chat when I had a few minutes and make sure they didn't need anything. Of course you feel sad when patients like these die. But it's a bit of a shock to open someone's chart and see "DECEASED" when the day before you were thinking about plans for discharging them. That is the kind of death that really hits you hard. I don't think there's much of anything you can do to prepare for that. I wasn't nearly as close to that patient as I was to some of the others, but so far that has been the death that affected me the most. The last thing this person said to me was, "it was nice of you to take the time to explain that to me." FWIW, I'm very glad that I did take that time.

 

[GWD]

Thanks all for the very sagely advice.

I've lost probably 100 monkeys by now, and I normally handle it quite well, but this one just got to me for a few reasons:

1) I was pissed. We are collaborating with another lab on this project, and they have TONS of private funding. Sometimes I feel like the work that they do can get a little sloppy because they have money to just throw around. For instance, the monkey that died (7270) was diabetic and received a beta-islet transplant. There were two other monkeys who were pancreatectomized to serve as donors. Well, to start with, their lab washed one of the pools of islets not in wash buffer, but in some sort of disinfectant (who knows where this came from), and that pool of islets was ruined. So not only was one donor animal just completely wasted, but now the recipient is off on a bad foot because he is only getting half the graft he is supposed to be getting.

2) Attachment. Most of the monkeys we work with, we do some sort of procedure in cohorts of 8-12 animals, and they either get sick and die within a couple of weeks, or they get better. Either way, you deal with many at a time, and you don't deal with them for more than 3 or 4 weeks at a time. Because this was such a chronic model, I had been personally treating 7270 for hundreds of days now. Also, for reasons of professionalism, and also to prevent us from getting attached to them, we aren't allowed to give them names. Our institution assigns them a number (i.e. 7270), but we had gotten this animal from another facility, and the reference number they had tattooed on him just happened to be "d1g1t," so of course we called him Digit.

3) Sympathy. The people who were ultimately making the call on this animal's fate were just sitting up in their ivory towers giving orders and didn't have to actually see or deal with this animal. I had to treat him everyday, and I was acutely aware of the state he was in, and the direction he was heading. The last time I saw him alive, it was really the most pathetic, moribund thing I have ever seen, and I've seen some pretty shocking things. I seriously was considering going into the food prep area, grabbing a kitchen knife, and slitting his throat just to show the poor thing some mercy. If I would have had a syringe of FatalX on me at the moment, I would have injected him with it without batting an eye.

So yeah.. I'm sure it never gets easy, but you do grow desensitized to it.

I'm sure I'll see much worse many times before it's all over... this one just really punched me in the gut for some reason.

It'll definately be one of those experiences you will never forget, and will also stick with you and affect you.

 

[QofQuimica]

This tends to be more common in residency than medical school since often the resident has gotten to know more patients and is handling sicker patients.

I was thinking earlier about this sentence of Tildy's post, and it made me laugh (not in an amused way). I'm not even halfway through my third year yet, and several of my patients have died. They are all very sick with multiple comorbidities that make us damned if we do and damned if we don't, and lately they've been making one-way trips to the ICU one after another. In just the past ten days, one of my patients died after being taken off a respirator; I was present for a code that happened while I was standing right outside the patient's room (not one of mine); and I have another patient who is in the ICU. That patient has been steadily getting worse ever since she came into the hospital. For the past week, I have been going to visit her every day in the ICU even though technically she wasn't on our service any more once she went to the ICU. On Friday when I let all of my patients know that I'd be gone for the weekend, this patient responded, "I'll miss you." She coded over the weekend and is now intubated with extremely poor prognosis. Today I only know she knew I was there because she squeezed my fingers when I told her to. I suppose this is one way to get the patients off our service, but it isn't quite what I had in mind. 🙁

Edit: Not sure if any of you are even still reading this depressing saga of a thread, but my patient coded again today and the family decided to take her off the respirator. Yesterday she was nonresponsive, so I wasn't surprised. But it's still incredibly sad.