Salvage

Generally speaking it's never a good sign if the word salvage is associated with your medical treatment. Whether salvaging a limb, salvaging heart muscle, or using salvage chemotherapy, things can only be kind of desperate and the outlook can only go from bad to worse. In hematology, salvage chemo is usually not well established, there aren't many controlled trials and even fewer good outcomes. Not saying it never works...just that working is usually defined in terms of extra months or weeks of life, rarely anything close to a cure. And sometimes just stopping and making the most of what's left is the best move. Our patient with fungal sepsis decided to marry her boyfriend and spend the last weeks of her life at home. I find it hard to fathom that turning point, where you're ready to give up on life, but at the same time rationally I think it's a completely reasonable decision when all remotely useful treatments have been exhausted. Grey's Anatomy actually had a really moving scene in the most recent episode, Suicide is Painless. A patient with terminal lung cancer describes how hope can be extremely damaging when you are ready to die. She's living in pain and there's no chance of a good treatment or cure...she wants physician assisted suicide and is happy with that choice. However, the thought of what if (what if there was a new cure, what if something had been missed and she's not really terminal) keeps her from being completely at peace with her decision, even when there really, truly is no hope. Insightful. There was also some annoying talk about Whoville...which as much as I love the Grinch Who Stole Christmas seems like a desperate attempt to start a catch phrase. I mean, SERIOUSLY. I miss the glory days of Grey's.

Speaking of salvaging. I spent the past week trying to salvage what remained of my medicine rotation. I definitely suffered for serious burnout right around the time I would normally be having spring break instead of working 13 days in a row. Now it's on to neurology which has it's own depressing set of problems and even less effective treatments. But at least it's spring!

Healing Hands

Hematology has been a different world from life at the VA. The new cancer center is amazingly nice...big, well decorated rooms, floor to ceiling windows, fake hard wood floors, a meditation room, a courtyard with a giant sculpture, bamboo, a staff sanctuary...it really does create a good atmosphere. Never underestimate the importance of beautiful pictures when you feel like hell. The rotation itself has been a little awkward, even the resident doesn't really operate with anything like autonomy, which I guess is how it has to be in a super subspecialized acute care setting. In one week I've seen lots of AML and multiple myeloma...along with ALL, CLL, ITP and some lymphoma. It's been interesting to see how adult oncology differs from pediatric oncology...different diseases (I'm actually glad I'm doing hematology not oncology since most pediatric cancers are leukemias), slightly different chemo regimens, and those poor adults have to be awake during bone marrow biopsies (I don't think I truly appreciated how painful they are). The tranquil setting definitely helps.

Today was an interesting day. I was grilled by my attending, Dr. F, over pulmonary and cardiovascular physical exam findings. Scary but actually super helpful...when I can get over feeling like an idiot, I definitely learn the most when doctors ask questions and really teach. I could use more of it. Then I got to observe Dr. F in his bone marrow transplant clinic and see him grilled by a similarly type-A patient who wanted to know his prognosis...not just statistics but a specific number of years...an impossible question. Dr. F's response "Only God really knows, and he hasn't told me". I could do without the God part, but I think it captures the degree to which outcomes can be very patient specific and hard to pin down despite all the risk stratification. Control what you can control because so much is out of your hands. One of our patients, a woman in her 20s with refractory AML, has been growing fungus in her blood and now it's spread to her skin despite anti-fungal therapy. She has no white count and she can't fight the infection until she has a white count which probably won't happen for several weeks, if she even lasts that long. No one has told her yet.

Speaking of God, today the director of palliative care and a hospital chaplain performed a blessing of the hands ceremony for all the doctors and nurses caring for cancer patients. It was very symbolic and beautiful...they personally washed each of our hands and anointed them with oil (?!?). I love the idea of the ceremony, "blessed be these hands that have touched life, and felt pain, and embraced with compassion" but it was also way too non-secular/O Holy God, for me. I'll happily swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, but I'm not about to join STO.

Good Medicine

Every morning this past month on the way to the VA I walked past the remains of an old hospital being torn down. Quite impressive actually, watching a building get ripped apart (though who knows how many toxins I inhaled), but also kind of depressing. And that's how I felt with my month at the VA...one chronic health problem after another slowly destroying these patients until something like cancer or an MI comes along and really knocks them down. There's not really a good endpoint...sure you can try to fix the acute situation, but death is always there somewhere. Plus I felt like every single patient had diabetes, hypertension, chronic kidney disease, hyperlipidemia and BPH. Good grief! They could be my dad!

Don't get me wrong, I actually really enjoyed the month...I liked talking to the veterans, I liked having a little more autonomy (or at least the illusion that I could make some of my own treatment decisions), and the hours were quite nice. I'd gladly do my sub-internship there next year (hopefully this calendar year) since I know how to work the system now. But so many patients just waiting for placement in nursing homes? So many patients coming in for altered mental status due to alcohol or drugs? So many patients in for COPD exacerbations with 150 pack year histories of smoking? Give me peds any day. Though I have to say I'm now a little torn on whether I'd want to do a Med-Peds residency instead of just a straight up peds residency. When I think of the quintessential doctor, it really is an internist. There is a huge array of medical problems you'd just never see in a peds setting (though apparently diabetes, obesity etc. are becoming bigger peds issues...yay), and I feel like for my own knowledge I want to know how to properly manage those diseases. Especially if I end up doing anything global health related...I've got to be ready for anything.

Today was my first day on the Hematology service at University...back into the world of chemotherapy, ANCs, and lots of things that are totally over my head. So much to do this month...hopefully I'll keep it all together.