Life at the VA

These days I'm at the VA hospital in Seattle, having moved on from Harborview (I'm still on my Internal Medicine rotation). It's a totally different patient population, but the vets are friendly, tend to see you as their doctor even though you're a student, and they usually have chronic diseases like emphysema or heart failure. So far I have only had male patients at the VA and they are generally over 65. My team has not had any patients who are returning from Iraq or Afghanistan, and I think this is because there is a large military hospital south of Seattle by Fort Lewis.

In my experience so far, the patients at the VA tend to be a little sicker than at Harborview, but this is probably because they are usually older and because unlike at Harborview, our team at the VA has patients in the ICU.

This week two of the patients on our team died. I was with one of the interns to pronounce the patient dead. This requires making sure that the person's pupils are not reactive to light, and then listening for heart and lungs sounds. Both of the patient's on our service had severe liver disease, and they and their families had agreed that they receive only "comfort care". In addition to being DNR (meaning that if they stop breathing or their heart stops, we will not perform CPR or go to extreme measures to prolong their life), they are taken off all monitoring and are made comfortable assuming by treating any pain that they may be in. These people are usually extremely sick, with nothing that can be done to cure them or restore some quality of life. Making them "comfort care" allows them to die naturally, without the trauma of a code (emergent resusitation), which usually breaks ribs, can puncture lungs, can be tragic for the family to see. Moreover, codes usually either don't revive the patient, or lead to a proctracted period of respiratory support in the ICU, with the family having to decide what to do.

When I was on call almost two weeks ago, I admitted a patient who had renal failure which was caused by urinary retention due to benign prostatic hypertrophy (BPH - watch the evening news and you'll see ten commercials for BPH drugs). He also had blood in his urine and was severely anemic. He was stable when he was admitted, and basically all we had to do for him was drain the 3L (that is a massive amount, by the way) of urine out of his bladder with a catheter to relieve the pressure on his kidneys and then watch his renal function hoping that the damage hadn't been permanent. One of the great advantages of being a medical student is that I have lots of time to talk to the patients, and I had gotten to know this gentleman very well. Once I got over the fact that he was originally from Canada, I learned that he had been quite an athlete and outdoorsman, and had done extensive mountaineering and hunting in Alaska. He told me he decided at a young age that he would live for love and adventure and had been successful on both accounts. He had recently been working as a gardener (he is 74), but had experienced gradually worsening fatigue in the past six months or so. As you might infer, I took quite a liking to this gentleman.

That night while I was reading up on renal failure and hematuria, his urine became more and bloody until the bag which his collected it looked like it was filled with blood. He continued to feel fine, but when his labs came back in the morning, he had become dangerously anemic (for you medical types, his Hct dropped from 25 to 15) and needed to be transferred to the ICU. It was a little harrying to discuss the new plan with my senior resident, which now focused on immediate planning should he go into shock. This entailed placing two large-bore IVs, one in each arm, calling the blood bank and writing his orders for ICU transfer. This was my first patient whose condition I watched rapidly deteriorate and it affected me more than I would have anticipated. Meanwhile, the patient himself was nonplussed and without new symptoms. I think he realized that I was more alarmed than he, and was even a little amused by this.

We transfused several units of blood into him, and several days later his urine cleared. His kidney function has improved, but not to normal and now he is waiting to be seen by the urologists to determine the cause of his bleeding.

Experiences like this are one reason I would not want to be an ER physician. It's a special experience to take care of patients throughout their time in the hospital, to see them every morning, ask them how their doing, check their labs every day and modify the plan. Sometimes when you meet them, you can't make a diagnosis, but over the course of hours or days, the pieces start to fall into place. Sometimes the patient gets better, sometimes you can only stabilize them, and sometimes they are found to have a chronic disease (like renal failure) or worse, a terminal diagnosis. No matter what, it's a unique and privileged experience to be with a patient as they go through what is often a life-changing experience.