waiting room

Its a hospital. But its also a waiting room and airport of sorts. People are going places.

Tonight I took out a chest tube (my first time). The old man’s skin hung off his limbs in giant folds, he was wasting away. He told me he was from Western NC , I explained that i too was from the beautiful blue ridge mountains. I made his bandage in the shape of a star (as my favroite surgical attending faitfully taught me) and we both commented on how easy it to see the stars from the tops of our beloved mountains. He looked me straight in the eye at the end of the procedure and said can I go home tomorrow?  His gaze held mine…I’m dying he said and I dont want to die here, I want to see the stars.

She was younger than my mom, she had two kids a teenager and a preschooler, their picture was taped to her hospital bed, its the last thing she sees when she sleeps and the first thing she sees when wakes up. The day I met her it was her 20th wedding anniversary.  I told her congratulations and we offered to bring her a cake. She refused and said that they were going to celebrate when they left the hospital. Her cancer had eaten her spine, into her ribs, she had been ravaged by infection leaving her respiratory muscles atrophied. Each breath required effort.  We did everything we could but it was like holding on to a giant handful of jello, every time we seemed to get a grip on it, it slid from our hands. She had not seen her kids in two months, she had not wanted them to see her like this. I am going to go home from here, I am, she said.  She died yesterday morning.

He looks like Santa Claus. He is wearing Santa PJs that his grandchildren gave him. Out of his hospital gown is a small hose connected to a 1 L bag of bloody fluid flowing from the Man’s pleural cavity. We talk for a while about life, growing up in rural NC, falling in love, having kids, having grandkids. He tells me about his faith, I tell him about mine. He tells me his hope, his peace.  But there is so mcuh to tell, so many stories  to be told, so much to be remermbed and savored about life. I have to go to afternoon rounds, I tell him sad to end our conversation. He is going home in a few mintues. He says good bye and gives me a piercing glance, remmber me, tell my stories when i go home.

All of our protocols, medicines and procedures are familiar to us, it is a language we speak. But what do we do when we lose? We help our patients  live, but how do we help them die? Its more than just a DNR or full code.   I think I am supposed to be memorizing luekemias classifications and chemo protocols.  But what I can’t get past in the waiting, the dying and then living on.   How do we minister to the dying? What is healing to the dying? What is peace? What is faith?

Let us touch the dying, the poor, the lonely and the unwanted according to the graces we have received and let us not be ashamed or slow to do the humble work.

Mother Teresa

Int Med

On my third day of internal medicine I called for a Child Life consult. I know what you are thinking. I have gone off the deep end. No really, hear me out. Do you know what all my adult patients do all day……….NOTHING. They sit in front of their TVs and lay in bed. While we preach to them about lifestyle changes we promote coach potatoes. Now mind you some of them are really, really sick but those aside, I find the philosophy maddening. There is not as much as a newspaper laying around the adult floors. Occasionally a volunteer will come by with magazines but it’s a once a week occasion.

Furthermore, when people want to get up its not really encouraged, I had a wonderful little old lady who came in with chest pain which was eventually ruled to be non-cardiac. I mentioned to my resident that she walked at her nursing home with a walker and used a wheelchair to get around if we were afraid of fall risk. She had asked for these things. He shrugged and said her yeah she could ambulate. Two days more laying in bed, she had cellulitis and a cough. We sent her home a week later having not left her bed in two weeks in worse shape than when she got there with a PICC line and a lot of Vancomycin. And I really did throw up my hands in the privacy of a bathroom stall and be like DARN INTERNISTs, stop thinking just about the freaking medical problems with people, start thinking about people with medical problems.

Peds

Its day 5 of ceftriaxone and vanc, hospital day 6 for perostinal abscess in the lft distal femur s/p I and D, POD 4 for appropriately developed 14 year old is what her chart says. But to the pretty 14 year old with big expressive eyes, It’s Sunday…”I WAS gonna get baptized today, Momma got me a white dress to wear.” she tells me. “But now I am here.” She sighs and looks longingly out the window of her hospital room. For our counting of milestones it seems we have missed one.

Its day 14 of the second of 8 chemotherapy protocols, POD 0 for a port-a-cath insertion for a 3 yo well developed female with ALL. I finish my presentation and we walk into the room. My resident goes and sits down on the bed next to the petite three year old with a million dollar smile and a beaded crown cocked slightly to the left on her head. “You finally have your port” she says. “No more IVs.” The three year old raises an eyebrow, Its not a PORT, It’s a PORT-A-CATH” she says as if she explaining something complicated to a small child. “And it’s beautiful and I love it, today is a special day.” Indeed, another milestone perhaps not one that I check for on my development assessment but momentous never the less.

Its day 6 of methotrexate for a 17 yo with relapsed ALL. On exam her mouth is filled with erythematous white plaques and she is febrile. She lies in bed speaking in whispers. Her eyes are red and inflamed from the chemo and from crying.. Today is a milestone. Today is her 17^th birthday. We sing to her and she offers us a rare smile. I spent that afternoon, my last afternoon on peds painting pictures with her. I doubt it was how she imagined her 17^th birthday would be. But her smiles and paintings are beautiful and I treasure them. For a little while we transcend illness and I know she treasures that.

Milestones, we count them, we test them, we watch for them with great anticipation. We celebrate them with joy and pride as parents and with a smile and a check in the box as clinicians. Can she crawl, can he draw a circle, can he hold a rattle, can she drink from a cup, can he walk, can he say his full name while hopping on one foot and singing a song?? We are quick to note when a milestone is not met, prompt to seek out the appropriate intervention. When a child is ill, still there are more milestones. We count off the antibiotic days, the number of chemotherapy protocols, weeks in cast for a fracture to heal and post-operative days with great flourish and precision. Days, Months, years of a child’s life counted off easily roll off our tongue at rapid fire.

But in all our counting and documenting, we have to be careful to stop, to savor, to celebrate them. We also have to fight for them. One of the things that struck me the most on peds is that children with chronic illnesses have to fight for their childhoods. The Medical drama can consume their lives and force them to grow up so fast. The least we can do for these kids is let them be kids and not let their medical milestones and protocols monopolize their lives.

PS: Peds was awesome. The end.