Memories

The other day I had a pre-med college student shadow me for a morning. Shadowing a physician has got to be one of the most boring things in the world. I mean, I walk around, I talk to people, I write in a chart, and I think. She gamely took a lot of notes and seemed really interested. I was struck by how idealistic she was about medicine, and sometimes she asked me questions that I’d long ago stopped asking.

Like, “How did it feel when your first patient died?”

My initial response was, truthfully told, “I honestly cannot remember the first patient I had that died. Most people who I see die are the elderly who are near the end of their lives, and in some ways it can feel natural. It’s hard when younger people die, those whose time isn’t really up.” I doubt I said it quite that well, but that was the sentiment.

Still, it bugged me not to remember the first patient I had who died. Then I remembered, not necessarily the first patient that died, but the one that affected me the most.

There was a young woman, J, in her late thirties, or perhaps early forties. She had woken up with a bit of a headache, sort of like her usual migraines, and not thought much of it. As the morning went on, the headache got worse and she went into see her primary care doctor. When she was there, he noticed that her face was droopy and she was slurring her words. He sent her into the emergency room, telling us that it was probably an atypical migraine. The CT scan showed a very different picture and by the time we went into see her, her entire right side was paralyzed, and she was terrified.

Her mother had died at a young age of a massive stroke, leaving J behind with her two sisters to be raised by a single father, not an easy thing in those (or any) times. She had recently started birth control pills, which unbeknownst to her had made her blood more likely to clot and caused the stroke. She likely had had an underlying blood disorder that made her blood more likely to clot alone, and the contraceptives just exacerbated it.

At that point in a stroke, it was too late for her to receive the potentially life-changing powerful blood thinner that can break up a clot–it is only given in the first three hours after the onset of a stroke, and J hadn’t sought medical attention immediately when her symptoms began as she quite reasonably didn’t even think of something like a stroke. At this point, there was nothing to do but admit her to the hospital and wait to see what happened.

Over the next few days, the extent of the stroke became clear. By the next day she was no longer able to speak coherently. Her husband, B, had been at her side the entire time she was in the emergency room, and now he returned with their three daughters. As the next day went by, J slipped further and further into a coma, and eventually was brain dead.

I remember the attending physician, the surgical resident, medical resident, and myself, at that time a third year medical student, huddling in the hallway outside of her room and looking at each other with grim faces, understanding that she was going to die. Everyone was monosyllabic in their sadness and sense of loss. The attendings were trying to decide who would go and speak to her husband. I remember asking, “Has anyone talked to him about organ donation?” The medicine attending looked at me and said, “That’s a good idea.”

I assisted the surgical resident in the macabre task of putting a central line (a large IV catheter) into J’s chest to continue delivering fluids and nutrition to keep her body alive until the transplant team could arrive. I don’t know exactly where all her organs went, but I know that she was able to donate her heart, kidneys, lungs, liver, skin, and possibly other things. Other than the massive stroke, she had been in excellent health.

The last memory I have is walking past the waiting room after the transplant team had come and gone, after J had died, seeing her husband in the waiting room holding their three daughters while his father-in-law watched over, not believing this most impossible repeating of history.

Pox, redux

We took the girl back to the doctor on Wednesday, where they brought 5 pediatricians in to look at her rash.  Around this time I realized that the last time they had seen normal chickenpox was the same as the last time I saw normal chickenpox, which was on my own body when I was 6.   The vaccine came out in 1995, when all of us were in college or med school and thus the only cases of pox they’ve seen are atypical cases that happen in vaccinated children.  The vaccine is given at 1 year old, so the girl was just 3 weeks away from getting it.

Remember the children’s song “Miss Suzy had a turtle?” The turtle gets sick and Miss Suzy calls in 3 experts who all declare different diagnoses. “‘Measles!” said the doctor, “Mumps!” said the nurse, “Chickenpox!” said the lady with the alligator purse.” This is what it was like at the doctor’s office.

The longer she’s been sick, the more the rash has looked like classic chicken pox.  I’ve been taking pictures every day or so to document its progression.

April 4th

April 4th

This was about 3 days into the rash, when we took her to the doc the first time and was told that it was viral. Apologies for all the snot in the pictures.  Her poor nose was rubbed so raw that she screamed whenever we wiped her nose so we did it only when absolutely necessary.

April 6th

April 6th

A few days later, the cheek rash is a bit better but now you can see the forehead lesions starting up.

April 7

April 7

Now the cheek rash is better, but the forehead is looking worse. This is when we took her back to the pediatrician.  Of the 5 docs, 3 thought it was viral, one said pox, and the other came in silently and left silently.  I do not know what she thought.

April 9th

April 9th

She’s a complete and total mess here.  New cheek bumps, but what’s most prominent are the completely new vesicles on her chin that look like chicken pox. The stuff on her right cheek is an eczema flare.

April 9th closeup

April 9th closeup

Here’s a close up of the chin bumps, which looked like clear little blisters on a red background.

April 10th

April 10th

Now the forehead is much better, and you can see the chin lesions…

April 10th closeup

April 10th closeup

…starting to crust over. She also developed a new vesicle on her leg today.

April 11th

April 11th

Today most of her face is clear, and the chin lesions are entirely crusted over. Most importantly, she’s back! By that I mean that she’s happy, active, rolling around, scooting all over the place and just radiates joy from her core.

April 11th closeup

April 11th closeup

For those who think that chicken pox is a benign disease, let me disabuse you of that notion.  The girl was utterly miserable for 2 weeks.  Before we knew it was chicken pox, she did go to school for 2 days but that’s was it–really we should have kept her home and I feel a bit guilty about it.  She would have otherwise been home for 2 weeks straight.  Thankfully it worked out okay with my work schedule, but this would have otherwise been really hard.  She also developed a nasty yeast infection in the skin folds of her neck and behind her left ear (she sleeps on her left side) that was extremely painful for her.  I would have preferred that she never gone through any of this.

Of course, there’s a possibility that this isn’t chicken pox, and could just be some random viral thing. I’m going to have her tested at her 1 year visit–if she’s positive then there’s no need to give her the vaccine.  If she’s not, then god only knows what she had and I’m just thankful that it’s over.

Tabula Rasa

I deal with a lot of death, dying and suffering at my job.  Practically every day I have to tell people and their family members that they have an incurable disease, one that we cannot do much for except to relieve symptoms as the end draws near. Even for those who are not dying, the people I see are often sick, confused, and in pain.

This is one of the reasons I love coming home to the kids.  At their ages, they are still blank, fresh, full of life, with futures yet unwritten.  There is a book called “The Dead Zone,” by Stephen King (yes, also a movie and TV series), in which the lead character, Johnny, is afflicted with the ability to touch people and see into their future.  This becomes a burden as most of his premonitions are about pain and people’s deaths.  At one point, he holds a baby, apprehensive of what he will feel.  A relief washes over him as all he feels is the swirling of the undetermined.

On my more difficult days, I always think of this when I pick up the little ones and hold them close.  After spending so much time with people who are near the end of their life, it is a comfort to come home to people who are just starting out.

And faces like this always make me smile:imgp0560