Reflections in a Head Mirror

And there's a hand my trusty friend!
And give us a hand o' thine!
And we'll take a right good-will draught,
for auld lang syne.
-Robert Burns

It was the very last night of a difficult two-month rotation early in my residency. I was On Call. Exhausted. Burned out. Going-through-the-motions. Not having a good time.  

I was sitting at the intensive care unit console writing notes in the charts of two of the patients I was following.    

One young woman had taken a fistful of pills and then hanged herself. Her beleaguered family had tried very hard to help her over the years and now they were spending their holidays in the hospital standing vigil at her bedside. After this one final attempt to kill herself, the family hoped she might bring light to someone else’s life with an organ donation. My task was to keep her alive long enough for her body to clear the toxic levels of the medications she had ingested. I flipped through her chart and wrote my note. Family members walked numbly past me.  

In another bed lay a young mother who had been getting ready to go out for a New Year’s Eve dinner party. Her husband found her unconscious in the bathroom after having heard her collapse. After being rushed to the hospital, the scans confirmed that she had experienced a massive, certainly fatal brain hemorrhage. She was completely unresponsive and spiraling downhill rapidly. The family, dressed for an evening out, sat disconsolately at her bedside. I dutifully recorded my findings in her chart.  

As I sat writing, a song came on a radio nearby. I never really knew the lyrics but I recognized Dan Fogelberg’s voice. The song is a first-person account of running into an old friend.

We drank a toast to innocence
We drank a toast to now
And tried to reach beyond the emptiness
But neither one knew how.

We drank a toast to innocence
We drank a toast to time
Reliving in our eloquence
Another 'auld lang syne'...

Then the strains of “Auld Lang Syne” filled the air. I checked my watch. It was midnight. I put down my pen and called home, wanting to talk to Kathi.  

“Hi, sweetie,” I said. “Did I wake you?”  

She had been dozing. “Guess so. Hi, yourself. How are things going?”  

I scanned the patients in front of me. I looked at the family members moving in and out of the rooms. I looked down at the chart notes I had written. I thought for a second.

“Not well. It has been quite a day. I love you.”  

“Love you, too. See you in a few hours?”  

“Yeah. Can’t wait to get home. Happy New Year.”

---

The following is feedback received for this blog: As always, a well-written post. Thanks again for sharing! - Jen This story really hit home as I am dating someone who works in an ICU. There have recently been a couple rough nights after which he has had to emotionally unload in order to get past things.   I have had the unfortunate experience of having to sit two torturous nights in the same ICU prior to losing my (late) husband. I am proud to call him an organ donor.   Luckily, even though my sweetheart worked this past new years eve, it was a quiet night and was able to leave at 3:00am instead of 7:00am.   We appreciated the cherished time together. I know the value of quality time. - Karen Farra

If you can't explain it simply, you don't understand it well enough.
-Albert Einstein    


Holiday music plays in the background as I scan my Cancer Center clinic schedule for the day. Most of the names are familiar. There will be three or four new patients that I have never met, a few that are coming to the office for postoperative wound checks, a few that are returning for routine cancer survivor visits, and a few that have noticed alarming new symptoms. Over the course of the day, about 20 people will pass through the office. Their medical problems will vary but each one hopes to hear good news.  

Preparing for the day, I review scans and laboratory tests. Indeed, some of the reports will allow me to share happy moments with patients.

"The biopsy showed only scar tissue; there is no cancer!"

"The new scan shows that everything has gone completely back to normal."

"Surgery was completely successful; we removed all of the cancer and you need no more treatment"

"You have been cancer-free long enough that we do not need to schedule any more appointments."

These are wonderful moments!

Other reports, however, carry ominous warnings. I anticipate these discussions. Although there is no one "right" way to share bad news, I try to remember: Be honest. Be gentle. Preserve hope. Listen. Answer questions. Don't hurry.

"There are new findings on the scan that explain your pain."

"We found more cancer in the operating room than we expected."

"The treatments did not control all of the cancer."

"There are options for care."

"Even though we cannot cure the cancer, we will do all we can to help you and your family."

"We will not abandon you."

"I am so sorry."

During the day, I move from exam room to exam room. Good news here, bad news there. In one room, there is a sense of pure delight and celebration. The holidays will be merry! In the next, there are tears and a gradual realization that the world has been turned on its head. What will we tell everyone? By the end of the day, I will have fallen woefully behind during the complicated visits and then caught up a bit during the routine ones.

As the last patient heads to the parking lot, I move on to the next task. Clinic is not truly complete until I have prepared a computerized report for each visit — a note succinctly distilling the history, examination, reports, diagnoses, and plans. My task is to translate moments of joy and horror into a written form that will become part of the medical record.

Notes for the "good news" visits are a pleasure to write. I work on these first.

Preparing the notes for the bad news visits, though, is often very difficult. There are many things that I cannot understand and for which I know no words. At the moments when I find myself struggling with a note, I often realize that I am incapable of comprehending the issues with which the patient and family are dealing.

Medical records have a variety of purposes. They record what has happened. They document what needs to be billed. They help caregivers communicate. And, sometimes, while I am trying to capture a critical moment in writing, they can even be a means of healing all by themselves.

"Perhaps the most important thing we ever give each other is our attention."
-Rachel Naomi Remen


You have been cancer free for two years now. Congratulations!   

That was a terrible time. The whole time I was getting treatment, things were absolutely terrible! Just terrible!  

What do you mean? In what way?  

On top of everything else, we lost all of our friends! We were totally alone through all of the treatment.  

Your friends abandoned you? All of them?  

Every one of them! When people learned I had cancer, they stopped coming around. Later, a couple of them even told us, “I didn’t know what to say.” They really told us that!  

That’s common, I think. People sometimes don’t know what to say.  

Yeah, but it was terrible! There are several people we have never heard from again. We ended up with mostly new friends as a result. And that wasn’t the worst part.  

What was worse?  

My son told us that he couldn’t stand seeing me so sick so even he stopped coming over to visit me.  

Completely?  

I didn’t see him for over a year! Not at all. Just now, he’s starting to stop by again.  

Wow.  

You know — my wife and I — we went through this completely alone. Just the two of us. Well, we were alone except for the people who work here. They were great. Some of the people really made a difference for us. Otherwise, we were alone.  

[Pause]  

You people don’t realize how much impact you might have on someone while you are just doing your jobs.  

[Pause]  

Anyhow, things are going okay now.

Thanks for telling me this. See you in six months?  

Yeah, six months. I can’t wait.

Periodically, Milwaukee Public Radio will air one of my essays on its locally-produced magazine program, Lake Effect, The first essay, entitled "The Christmas Letter," aired last week. An earlier version of the essay appeared in the blog on 1-2-2009.

Thanks, WUWM!