Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Friday, January 20, 2006
    Death Watch

    Dr. Oscar London is right when he says "It's the young deaths that kill you." It's hard to lose somebody with good protoplasm who "should" be able to triumph over their disease, or at least could have several years ahead of them (with luck and good treatment). Nothing is more frightening or makes doctors feel more impotent than watching patients like that fail treatment. Right now V. and I are standing on the sidelines watching someone die.

    She is younger than either of us. She was diagnosed with cancer six weeks ago. She is in Intensive Care, on a ventilator, in multi-organ-system failure - actually, it's mainly her liver that is failing; it's riddled with tumor. She has breast cancer. She's under forty years old. We are trying chemo, treating her bleeding diathesis with fresh frozen plasma, doing all the things we can to keep her going. If she were ten years older, she'd already be dead, but no one's body can take this kind of punishment for long. Over the holidays I was covering V.'s practice, so it fell to me to tell this poor woman that her CT scan showed tumor in her liver (her initial complaint was persistent abdominal pain). She had only just gotten the results of the breast biopsy the week before. Now two weeks later she's in the ICU.

    Lately I've been thinking a lot of a case I saw as a new intern. My first rotation was in the ICU. One day a woman in her early forties came into the emergency room. She was in good health, had had the flu for several days, and came in because of shortness of breath. When I first saw her, she was able to talk and tell us about her illness; she was on a ventilator within the hour; one week later she was dead. It was pneumonia, followed by sepsis and organ failure. The culture results - I still remember this - showed uncomplicated strep. pneumonia as the causative agent. It wasn't drug resistant, it was even sensitive to penicillin, for God's sake! Why couldn't we save her?

    We're used to taking action, to implementing plans that work. When cases like this come along they remind me that I don't have the power I like to think I have. I can't fix people. I hate being reminded that diseases are smarter than I am. I hate feeling useless.

    I hate watching people die.



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