{"id":2062,"date":"2016-08-15T14:52:13","date_gmt":"2016-08-15T18:52:13","guid":{"rendered":"http:\/\/blogs.nejm.org\/general-medicine\/?p=2062"},"modified":"2016-08-15T14:52:13","modified_gmt":"2016-08-15T18:52:13","slug":"patient-education","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/general-medicine\/index.php\/2016\/08\/patient-education\/","title":{"rendered":"Patient Education"},"content":{"rendered":"
\"Jamie<\/a>

Jamie Riches, DO, is a 2016-17 Chief Resident in Medicine at Memorial Sloan Kettering Cancer Center<\/p><\/div>\n

We had known Ms. B. for weeks. She was a \u201cbounce-back\u201d to the unit. Every day, an intern would enter the ICU room and ask, \u201cHow do you feel?\u201d \u201c<\/span>OK.\u201d <\/span><\/i>Do you have any pain?\u201d \u201c<\/span>No<\/span><\/i>.\u201d \u201cAny trouble breathing?\u201d \u201c<\/span>No.\u201d \u201c<\/span><\/i>Tightness in your chest?\u201d \u201c<\/span>No.\u201d <\/span><\/i>\u201cNo? OK.\u201d<\/span><\/p>\n

I was the senior resident following the case, 1 of\u00a022 in the ICU. I walked in that morning and asked, \u201cHow do you feel? Are you nervous?\u201d \u201c<\/span>Yes<\/span><\/i>.\u201d We\u2019re trained as physicians to accumulate and analyze large amounts of information and condense it all into one-liners.\u00a0I\u00a0had known this patient as \u201ca 74-year-old female admitted with acute hypercarbic respiratory failure in the setting of a large pleural effusion, atrial fibrillation with RVR, diastolic heart failure, and an extensive prior course complicated by an acute cardiac ischemic event, refusing catheterization.\u201d That morning, the patient, whom I had also come to know as a dedicated mother, a strong-willed woman, and a funny, caring human being, was, in a one-liner, \u201ctired and scared.\u201d She was scheduled to have a thoracentesis that morning; we would remove fluid that had been occupying her lung space and test it for infections and cancer. We hoped the procedure would be diagnostic and therapeutic. She said she might not want to know if it was cancer. She just wanted to be able to go home. \u201cWe want that too, Mrs. B.\u201d<\/span><\/p>\n

Checklist: The patient was prepped in\u00a0sterile fashion, and the area was cleaned and dressed appropriately. Risks and benefits were explained: check. A time-out was performed: Patient name\u2014correct; Procedure\u2014correct; Site\u2014correct. Site was marked.<\/span><\/p>\n

\"Spanish<\/a>The patient sat at the edge of her bed with her arms outstretched across a rolling tray table. This was the table that usually held snacks, her small blue leather Bible, and the phone to call her son and daughter. Her children came to visit every single day and night. Today, the table held a plastic pillow, which crackled with the slightest movement. I squatted in front of the table and held her hands, while the fellow prepped for the procedure. \u201cWhat procedure are you having, Ms. B?\u201d,<\/span> the attending physician asks. \u201c<\/span>They just told you. I\u2019m having a thoracentesis.\u201d <\/span><\/i>\u201cAnd what does that do? What is the purpose of the procedure?\u201d \u201c<\/span>To take the fluid out of my lungs so I can breathe better.\u201d <\/span><\/i>The checklist was complete. <\/span><\/p>\n

Ms. B held her small blue leather Bible by her side every day. She prayed and thanked the Lord every day she awoke to breathe. Despite 18 years of Catholic school, I probably haven\u2019t \u201csaid my prayers\u201d since I had to be reminded to take a bath. <\/span><\/p>\n

\"school<\/a>\u201cWere you born in New York?\u201d, I asked. \u201c<\/span>I was born in South Carolina. My mother brought me here when I was 2\u2026 to be educated. I was educated in New York City.\u201d <\/span><\/i>She spoke with a pride that not only filled me with a sense of gratitude, it fractured me with guilt. I too was educated in New York City. I had always regarded my education as an expectation, as opposed to a gift, despite neither of my parents having attended college. Knowledge was, to a certain extent, a collector\u2019s item, to be acquired and displayed within various carefully chosen venues. My mother was hard on me when it came to my performance in school. If I scored a 98% on an exam, she would ask, \u201cWhat happened to the other two points?\u201d I had never been any more <\/span>proud<\/span><\/i> of my education than proud of my ability to wake up every day and brush my teeth. I’ve been reminded on more than one occasion that I do not have a \u201cpedigree.\u201d As an older African-American woman, Ms. B remembered a time when simply attending school was a right to be fought for. <\/span><\/p>\n

\u201cI like your scarf,\u201d I said. Ms. B wore a bold orange headscarf with an asymmetric bow. I\u2019d seen her wear it many times over the course of her stay. There was something fearless about that scarf. \u00a0<\/span>Silence.<\/span><\/i> \u201cAre you nervous?\u201d \u201c<\/span>Yes!\u201d Silence. <\/span><\/i>\u201cWhat kind of music do you like?\u201d \u201c<\/span>The Blues… and I love Christmas music. It just makes me happy.\u201d <\/span><\/i>I placed my iPhone on the tray table and opened a Spotify playlist called Christmas Hits. \u201cI\u2019ll Have a Blue Christmas Without You\u201d was the first song. I made a joke about the song being best of both worlds. <\/span>Silence. <\/span><\/i>I found out during our conversation that she loved scary movies and zombie shows. \u201c<\/span>I love The Walking Dead, Night of the Living Dead, all those shows.\u201d<\/span><\/i> I told her that I can\u2019t watch those shows because I am actually afraid of them. \u201c<\/span>They don\u2019t scare me.\u201d\u00a0<\/span><\/i><\/p>\n

Her hands were small. There was a cyst on her left little finger, which I hadn\u2019t noticed before, any of the times I\u2019d seen and examined her. I wondered what other observations I\u2019ve failed to make. \u201cDoes this hurt?\u201d \u201c<\/span>No.\u201d <\/span><\/i>\u201cHas it always been there?\u201d \u201c<\/span>No.\u201d <\/span><\/i>\u201cWhat happened?\u201d \u201c<\/span>I was carrying a heavy grocery bag, and it never went away.\u201d <\/span><\/i>When she felt discomfort or anxiety, she would quietly dig the tip of her fingernail into the pad of my gloved finger, staring straight into my eyes. I have the same self-soothing mechanism: I press the pads of my fingers, subtly and often subconsciously against the edges of my fingernails, bilaterally and symmetrically, until I\u2019ve traveled from my indexes to my little fingers, and occasionally I\u2019ll start the process over again from there. I usually don\u2019t recognize my own nervousness until someone looks at my hands and says, \u201cAre you OK?\u201d<\/span><\/p>\n

I whistled along to \u201cLet It Snow\u201d as the fellow continued with the procedure. The procedure was simple, \u201cuncomplicated\u201d as we say, no bleeding, no hemodynamic instability, no pain. Her son and daughter came in patting her on the shoulder, <\/span>\u201cYou did great mom! See? You did great.\u201d<\/span><\/i> We all left the room to begin rounds. A post-procedure chest x-ray was unremarkable; decreasing pleural effusion, no evidence of pneumothorax. Ms. B spent the morning with her children and sister, breathing more comfortably. \u201cShe\u2019s doing great!\u201d<\/span><\/p>\n

Later that afternoon, a nurse told me that the patient was having some difficulty breathing. When I arrived in the room, Ms. B’s heart rate was rapid and irregular. Simple breathing was laborious, and her face wore the expression of desperate fear. \u201c<\/span>Not the mask! No mask!\u201d <\/span><\/i>She had intermittently required a biPAP mask to support her breathing. She hated that mask. We thought the thoracentesis would alleviate its necessity. As I placed my stethoscope on the right side of her chest, I heard no sounds to accompany the arduous rise and fall of her ribcage. \u201cWe need a STAT chest x-ray!\u201d The x-ray looked as if the image were split in two and inverted, as if the right side was a negative. Hemothorax. \u201cShe needs a chest tube,\u201d the attending said. <\/span><\/p>\n

As they prepared for a second procedure, I walked outside and placed my hand on her son\u2019s shoulder. He was a large, loud, boisterous man who many of our staff members found intimidating. He had a plethora of very specific questions every day. The attending reviewed the new procedure with him, and he looked at me, timidly, with the same frightened eyes I had seen earlier that day. \u201c<\/i><\/span>Is she going to be OK tonight, Doc? I\u2019m scared.\u201d <\/span><\/i>He previously had never called me anything but my first name. \u201c<\/i><\/span>What\u2019s going to happen?\u201d <\/span><\/i>\u201cI don\u2019t know,\u201d I said, \u201cbut we\u2019re going to do everything we can to take care of her.\u201d I walked away to the next room, to check on another patient, a \u201csick patient,\u201d a GI bleeder receiving his 5th unit of PRBC repletion under our massive transfusion protocol. This was my education, my training as a physician, education that I was not always grateful for in the moment.<\/span><\/p>\n

\"asystole\"<\/a>

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http:\/\/creativecommons.org\/licenses\/by-sa\/3.0)], via Wikimedia Commons<\/p><\/div>Overhead, the operator called, \u201cMEDICAL CODE STAT TO ICU SOUTH, ROOM\u2026\u201d\u00a0There was a cardiac arrest in my unit, right where I was standing. I started to run. \u201cWho is it?\u201d My chest became\u00a0hollow\u00a0as I realized who it was. Ms. B was dead. As we rotated through cycles of chest compressions, I felt her <\/span>third and fourth ribs shatter<\/span> shatter under my palm. My abdominal muscles burned. I knelt on the bed next to her and used my weight to compress. Her face no\u00a0longer wore\u00a0any expression of fear; she was lifeless. Her orange scarf, missing. \u201cPulse check.\u201d Nothing. After [what seemed to be countless] minutes, she regained a pulse, which she was able to sustain long enough for her family to come in. She was unconscious and\u00a0immobile, with a tube entering her mouth and another exiting her thorax, draining liters of blood. \u201c<\/span>Mom, you were the best mother.\u201d <\/span><\/i>Her children were draped across her bed, praying, crying, praising her life and her accomplishments, pouring out gratitude. \u201c<\/span>Jesus will come to this room tonight!\u201d <\/span><\/i>We stood and watched, fully aware of the transience of the pulse.<\/span><\/p>\n

The last time I saw my own mother alive was in the ICU. We decided to place a DNR order before she died, knowing she wouldn\u2019t have wanted anything more.<\/p>\n

As the line flattened on Ms. B\u2019s monitor, I knew the next series of chest compressions, shocks, and epinephrine pushes would be the last. \u201cI\u2019m running this.\u201d Running a code had formerly been my most feared responsibility. I remember my\u00a0intern year as if it were yesterday: chest compressions, running to the lab, grabbing the chart, being grateful to do anything except run the code. Throughout my training, this task has become like many others: systematic, ordered, implemented without difficulty. In this moment, I felt an enormous responsibility: to assure that we had done everything possible to give our patient and her family what they needed in that moment [for them to know they had done \u201ceverything\u201d], to provide her the dignity she deserved in her death, to spare her from any excess undue harm, and to honor and care for her until her time of death. \u201c6:53 PM,\u201d I said, with final and deliberate certainty. Tears immediately filled my eyes and began falling in rapid succession as I stood, surrounded, witnessed by, the entire ICU team. The nurses rushed to the patient\u2019s body to clean and dress her for the family to view. The family stood outside, intoxicated with fear, shock, and sorrow. \u201cLet\u2019s go,\u201d one of my co-residents said, as she escorted me to the stairwell where, for a few sacred and uninterrupted minutes, I cried. I cried until it was time to wash my face, sign the required documents, and gather my papers for evening ICU rounds. \u201cCheck MR. F\u2019s urine output overnight and dose the Lasix accordingly\u2026 Try to taper Mrs. C\u2019s levophed…\u201d<\/p>\n

These are days where we not only experience but also participate in and often direct the most poignant moment of someone\u2019s life;\u00a0then, we\u00a0move on with apparent simplicity. I\u2019ve not had any more intimate experience than to learn someone\u2019s history, wishes, and fears, to listen to her words,\u00a0her breath, and her heart\u2026 to feel the contours of her hands, the fragility of her ribs, her fleeting pulse\u2026 and to witness her last breath. <\/span><\/p>\n

I walked out of the hospital at midnight and, as I waited for a cab at the entrance, Ms. B\u2019s family emerged, one by one: son, daughter, sisters, brother, in-laws\u2026 We hugged and cried. They told me they would take her home to South Carolina to be buried. \u201cThat\u2019s good.\u201d They thanked me for saying \u201cI don\u2019t know.\u201d I said, \u201cI\u2019m sorry.\u201d\u00a0\u00a0I <\/span>was<\/span><\/i> sorry. I <\/span>am<\/span><\/i> sorry for their loss, their pain, their mother\u2019s suffering. I am also grateful to have had the experience of knowing her and her family, to have taken care of her, to have <\/span>learned<\/span><\/i> from her experiences, both good and bad… to have been changed by her gratitude. <\/span><\/p>\n

Days later, I couldn\u2019t stop thinking about this patient and how much she taught me. Although it felt strange, I googled my patient\u2019s obituary. Among the many lines, it reads: <\/span>She was educated in the New York City public school system<\/em>.<\/span><\/p>\n

 <\/p>\n","protected":false},"excerpt":{"rendered":"

We had known Ms. B. for weeks. She was a \u201cbounce-back\u201d to the unit. Every day, an intern would enter the ICU room and ask, \u201cHow do you feel?\u201d \u201cOK.\u201d Do you have any pain?\u201d \u201cNo.\u201d \u201cAny trouble breathing?\u201d \u201cNo.\u201d \u201cTightness in your chest?\u201d \u201cNo.\u201d \u201cNo? 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