My Diabetic Patient, My Dog, and Death

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mandy4

 

I don’t remember his name.

 

There is so much detail surrounding those few hours, so many bits of sound, sight, and emotions that are etched into my brain. The sweat. The knot deep in my chest. The agonal breaths. The tears that I was desperately trying to hold back. And yet, his name eludes me. However, he will always be the first human being I saw die. The word “saw” doesn’t seem to do it justice, mostly because I was hardly a spectator in his death. I experienced it with him, walked with him down his dark road before letting go. And even then, I only let him go physically, as this memory, this experience, will be carried with me until it’s my time to die.

 

This is a post about death, so turn around now if you’re not in the sort of somber mood that makes reading this bearable.

 

I was on trauma call with my attending general surgeon during my third year of medical school, and he left me to hang out in the emergency department to catch any sort of surgical trauma before he would be called. As he introduced me to one of the emergency medicine physicians, I felt like he was dropping me off at the local pool and would pick me up in a few hours after I was done playing. I had no idea what I was in for, but the first few seconds I spent with that physician made me realize I was in for a night I would never forget. I’m going to call him Dr. A (and no, his name has no A in it) for simplicity’s sake.

Dr. A seemed to be in his late 50’s and stood about 5’8″ (let’s be real, everything below about 5’10” is all the same to me, so he could have easily been 5’3″. I digress), with dark hair combed over where his hairline had receded. He wore a pair of beat up white New Balance sneakers and dark green scrubs, which were hospital issue. He had a fairly regular sort of face except for between his nose and receding hairline. He had thick, dark eyebrows that seemed to be permanently furrowed, along with deep creases in his forehead that had seen thousands of patients and countless hours of deep thinking. He wore thin-rimmed wire glasses, and behind them sat the darkest, most intense pair of eyes I have ever seen. His eyes darted about, not out of nervousness, but so as to not miss a single detail of his surroundings. When I shook his hand, he stared right through my squishy little eyeballs. I could feel him analyzing my fears, my anxiety, my triumphs, my abilities. He scanned me from head to toe like a typewriter. Slowly. Methodically.

 

“What do you want to do with your life?” were the first words he said.

“Surgery”, I replied confidently, but with a twinge of hesitation due to having been examined by his eyes from the cytoplasm of my cells on out.

 

He proceeded to drag me over to his desk and said, “We’re going to see if you have what it takes to be a surgeon”, and proceeded to ask me a flurry of questions about my background, my previous athletics (basketball), and every area of my life. Upon seemingly passing his tests, he said, “If you want to do surgery, John is the guy. I’m going to call him right now. If you want to do surgery, it’s John’s way or the high way”. Mind you, this was at about 10PM on a weeknight, and John was a 4th year student who Dr. A was very, very fond of. Luckily, he was a student from my school who had mentored me over the past year when I found out he was applying to surgery residency. So there I was, having a 10 minute conversation with John about surgery and what I needed to do over the next year, with Dr. A running around and pausing to look over my shoulder every now and again. After saying bye to John, Dr. A seemed pleased, and told me it was time to get to work.

He proceeded to treat me like I was rotating in emergency medicine (and mind you, I was both a fairly new third year AND on my surgery rotation at the time) and sent to see patients. He blitzed me from every angle with questions and medicine tips, including his magic cocktail of how to fix someone who has food stuck in their esophagus.This was because we saw a man who got a gigantic piece of steak stuck in his throat. I still have that written down in one of my tiny blue notebooks. It reads:

 

Esophageal Foreign Body

IV fluid bolus

Rapidly, give these three things all at once- 2mg glucagon

3 doses 0.4mg sublingual nitro

10mg bite + chew procardia (which reduces lower esophageal sphincter pressure)

Maybe one day I’m going to use this, as the patient swore that Dr. A had saved his life with his method. I found a prescription paper in this same blue notebook with Dr. A’s contact info, phone number, and a recommendation of a book: “My Losing Season” by Pat Season. I’m going to have to read that.

 

Anyway, what I learned from this time was that not only was Dr. A a little crazy, he was a genius. He was the kind of “mad scientist” physician who had a mastery of all things medicine, and would be the type of guy I would want taking care of me in a pinch. He had a few bizarre (and frankly inappropriate) comments that I won’t repeat here, but he that’s just how he was. He had the energy of a sprinter with the endurance of a marathon runner. It was incredible to watch him work. It was within about 2 hours of me being there when he frantically pulled me out of the room I was in and said, “Come, you’ve got to see this”

As we nearly sprinted down the hall, he asked me if I had ever seen someone die before. I said no. That was about to change.

At the door to the room, we paused. In bed was an elderly man, in his late sixties, who was in florid congestive heart failure. He came from a nursing facility. Heart failure is when your heart no longer pumps like it is supposed to, basically not squeezing as hard as normal. When it gets to being very weak, your body starts to not like the lack of blood flow, and you can no longer get enough oxygenated blood to your tissues.  Additionally, blood can become stagnant inside the lungs, because it isn’t getting pumped forward, and fluid leaks out into the lungs, creating what is called pulmonary edema. Our man in that room had all of the above, and his heart was completely failing. He had thin limbs, a gigantic barrel chest, and appeared weak and tired.  His eyes were closed and he was becoming increasingly short of breath. He was disoriented and unresponsive, I’m not sure at this point that he knew what was going on. I’d guess it was due to lack of oxygenated blood flow to his brain as well as extreme fatigue from fighting this losing battle.

Dr. A turned to me and told me that it was a matter of time until he passed, likely within an hour or two. There was “nothing we could do” to cure a condition this bad. But as a physician would later tell me later in medical school, “That doesn’t mean there’s nothing we can do”. Dr. A told me to stay with him, and after ordering some morphine, promptly left the room. The nurse followed shortly after him. I was left alone.

 

There are surreal moments in medicine that cut through the tough exterior built up after years of numbing experiences. One year of dissecting donors (also known as cadavers) and exploring the human body will turn even the most volatile of stomachs into iron. Top that with being elbow deep in someone’s bowels in surgery, seeing patients incredibly sick and on a ventilator, and seeing someone disfigured after a motor vehicle collision, and you’ve got a recipe for a thick candy shell protecting our soft, squishy insides from the horrors of this world. As I was left alone with this gentlemen, I realized I was staring death in the face, standing on the cliff between known and unknown. The beeping of the heart monitor was like a drunken metronome, occasionally wildly speeding up and slowing down. He was having alternating tachycardia (fast heartbeat) and bradycardia (slow heartbeat) of someone dying of heart failure. My mind clung to that familiar sound, providing some semblance of normalcy despite the situation in front of me.

I just….stared at him. I slowly looked at his breathing, his movements, how he was laying there. I wasn’t sure how else to grapple with the fact that I had been ordered to watch this man die. I realized the worst part: he didn’t have a single family member or friend with him. Dr. A hadn’t mentioned getting in contact with any family (in hindsight, it was probably done while I was in the room). I was going to be the only person with him while he died. I wasn’t even sure if he could hear me, understand me, or knew what was going on. All I knew was that nobody deserved to die alone, even if a complete stranger is the one preventing that.

 

I finally got the strength to move my legs, and walked up to him and held his hand. I stared at the monitor, I stared at him. I told him things were going to be okay, that he wouldn’t go through this alone. I don’t think any part of my little over two years of medical training qualified or prepared me to do this. His gasping and twitching movements continued, and there was no indication that he heard what I said. I choked back a tear or two (or twenty) as I thought about how nobody who knew him was here to love him, to see him off. At this point I tried to calmly pray for his soul, for him having a comfortable passage into death.

All semblance of time was lost by then. Dr. A and the nurse came in briefly to check on him. Dr. A pulled me out of the room for a second, where he and the nurse had a discussion about what to do. She, openly crying at that point, wanted to transfer him up to the floor so he didn’t have to die in the emergency department. He flatly, and briefly, refused her request. She wasn’t happy. I went back into the room.

 

Many times his heart rate slowed to the point where he would go into an arrhythmia, but he bounced back up to a normal sinus rhythm. I was told to go get Dr. A when the patient died. So I still sat there, trying to tell this dying man a funny story or joke or anything that came to my mind. Numb, I ran out of words and only squeezed his hand tighter. He seemed to go to the brink of death and back, breathing more and more slowly until it would eventually pick up; the intervals between his recovery to his normal respiratory rate became longer and longer. Finally, he seemed to exhale slowly, almost puttering breaths out, and they became softer and softer until they were no more. His heart stopped beating. The nurse came in, wiped her eyes, and walked out. There I sat, watching the monitor. I had no idea who he was, and I shared one of the most intimate, and final, moments of his life. He had found rest, finally been relieved of his suffering. In a way, I was relieved, but the world seemed mute, dreary.

 

Dr. A came in to perform the declaration of death. He showed me how to use the ultrasound machine to look for any heart movement, and other aspects which I can barely remember. He told me it was time to go, and I took one last look at the dead body that now lay in front of me, squeezed his hand one last time, and walked out of the room.

I don’t remember much of what happened between then and when I finally left, except that Dr. A took me aside at whatever late hour of the night it was and talked to me about a variety of topics. He talked about the nurse and how she wanted to dump off the patient’s death on some other unit. Among using some choice words about her fear and it being ridiculous, he told me to not be afraid of death, and as physicians it is our job to embrace it and accept it when the time comes, and help our patients get through it. He stated that by giving him morphine to ease his pain and by simply sitting with him, we had done more than we would ever know.

I left that night feeling drained. I sat in my car for five minutes before I finally stopped crying and got the courage to leave. For a brief moment, I wished that someone from his family could have come in so that I didn’t have to be with him. It was selfish. It was unfair. I then felt thankful that I got to share that moment with him, whoever he was. I knew nothing of his life, his joys or sorrows, and yet there I was, somehow destined to be there in his death. I drove home blank on the inside, wanting nothing but a deep sleep. I remember falling asleep right as my head hit the pillow, only to awaken to the shrewd sound of my alarm. I got up, put on my shirt and tie, and headed off for another day as a medical student. In a way, nothing had changed.

 

 

With that being my first experience with a patient death, it was hardly the last. That gentleman made me think a lot about death after that, and to this day I hope that death never ceases to strike me to my core, reminding me about all that it means to be human. That it strips away all my medical training and makes my heart ache a bit, that I feel that knot in my chest. I never want that feeling to be lost, so I can always remember the privilege, the sanctity, of life.

However, that situation was a bit different from that which I will experience numerous times in my career: having one of my own patients die. Having someone that I had care for or tried to heal pass away. That happened on my internal medicine rotation (basically general adult medicine) shortly thereafter. We had a patient, who I will call Mr. B (and yes, I do actually remember his name, but it has nothing to do with B), who came in for management of some leg wounds and a surgical consult. He had gone years without medical care, and when he finally made it to the hospital, he found himself diagnosed with a host of new conditions, including diabetes (which caused his leg wounds), high blood pressure, and more. (Side note: this is common for those coming into hospitals for the first time in years, which is common in a trauma or accident. We tend to find a lot of chronic conditions which have gone untreated). By all accounts he was doing fairly well when he got to us, and was on track to go home in a week or two, albeit with a host of new medications.

I talked to him a few times, and he was “my patient”, as medical students pick a patient or two or three and try to play doctor, working with the resident and trying to act like we have any influence in care (hint: we mostly don’t, at least not directly). He was a bit of an odd fellow, but was very nice and always appreciative of what we did. He had made good strides, and was beginning to be able to walk again with the therapist.

 

This particular morning on rounds, Mr. B looked a bit pale and complained of some hip and back pain, but was still feeling otherwise well, so not too much was made of it. Later that day, I was at one of the seemingly endless lectures of this particular rotation when one of my residents noticed that Mr. B had looked more pale and seemed a bit out of it (we call this a change in mental status). She promptly got a complete blood count (CBC) which showed a low hemoglobin count relative to yesterday, indicating that he was bleeding from somewhere. Promptly, she did a CT scan of his abdomen which revealed a hematoma, also known as a blood collection, which had gathered in his abdomen. I found out about this right as I arrived back to our team room. Mr. B was rushed down to interventional radiology in an attempt to stop the bleed, which was supposedly successfully stopped.

 

That night, I went to his room, which was now in the intensive care unit, to see him. At the time, being the inexperienced med student I was, I thought that he was doing fairly well and just out of it from the procedure. I told my residents he was “doing okay” when I got back up. I was embarrassed to find out that when my residents went to go see him, they said he “looked like death”, which made me realize that my initial assessment was way, way off. In hindsight, his low blood pressure, altered mental status, pressor requirements, and lab values were very much consistent with the “oh sh*t” end of the spectrum. It was an easy move for a rookie medical student to make.

We followed him from the periphery over the next week or so, and heard that his organs had begun progressively failing despite the ICU’s best efforts. It was days later that we heard of his passing. He was my first patient who had died. Just like that. I had talked with him only a week before about fishing, about Star Trek, and about life, and now he was gone. It was disheartening to know despite the medical brilliance and swiftness that my resident displayed to recognize the problem so quickly, it ultimately ended in death. The jury is still out as to why the bleeding started (most likely due to his medication to prevent blood clots), but it made me realize that sometimes things are out of our control. Despite all our efforts, advances, and even when we make the right call at the right time, it can still end in failure….also known as death.

 

Failure means a lot of things in medicine, and to physicians it can seem that death is the ultimate form of failure, especially in situations where we make the right intervention and  still cannot control the patient’s disease. We can fail when we give the wrong medication causing an allergic reaction, or nick an artery in surgery and have to repair it, but this was probably the second worst form of failure (with the first being screwing up and causing a patient’s death). Sometimes death wins. It was different than the first patient I saw die, he was already a casualty of his disease. Mr. B had started out as a frontrunner to survive and saw a rapid decline. Even though I wasn’t the resident (AKA the one doing the real doctor-ing), I still hurt as if I had been the one making the decisions. The worst part is I don’t know who was with him when he died, if there even was someone at all.

 

 

The phone call that prompted this post came about three months ago as I was in the middle of some stupid video game, my mom called me sobbing. She had been away with one of her friends and had put our 16 year old beagle, Mandy, at the vet kennel (because she was sickly overall) for the weekend. It was something she rarely did, but we felt it would be okay this time. Between her crying, she was able to say “Mandy died” before going back to uncontrollable crying. She was on her way home from Northern Indiana to pick Mandy up when she got a call that Mandy was going to need a procedure (for what I can’t remember). She had consented, and shortly after she got a call saying that when they went to get her for the procedure, she had closed her eyes and didn’t wake up.

We all knew that she wasn’t in the greatest of health for the past year, as she had some type of slow growing cancer, bladder incontinence, and her joints had been failing, makign it sometimes difficult for her to walk around. But she still did a lot of the things she loved, mainly sleeping, begging for food, going for slow walks, and laying out in the sun. My mom was beating herself up about not being there for her death; although, it was arguably better this way because she didn’t have to see it happen live, which probably would have crushed her. She had always prayed that, “God when her time comes, just let her close her eyes”. In this case, it had come true. I said a quick thanks to the powers at be that it had happened this way, and set off from my apartment to meet my mom and brother at the animal hospital.

 

By the time I arrived, my mom was a mess. She had been crying for over an hour as she drove back home. It hit her hard. While I was away at college and medical school for the past 7 years, and my brother at college for the past 4, Mandy had been the one with her through it all. She helped the empty nest not seem so empty. Mandy was the first dog we had ever had as a family, and despite not being the first dog my mom had die, she was the first one who was truly hers. Now she would be alone at home for the first time ever.

We sat in a conference room while waiting for them to bring Mandy for us to say our goodbyes. It was a room they clearly used for this purpose, as it had a terribly tear-inducing poem on the wall I believe called the Rainbow Road, as well as advertisements for a weird pet cemetery. We all cried together a little bit, my brother and I tried to keep our composure as best we could. When it came time for them to bring her in, they opened the door and wheeled her in on a table. She looked…at peace. Calm. Like her suffering from her many medical ailments had stopped. She looked like she was sprawled out in the grass, just sleeping and soaking in the sunlight. It seemed she would wake up at the slightest sound. And knowing her, she would walk away from me the moment I’d sit down next to her. I swear she loved me but hated me all at the same time.

 

We reminisced about all kinds of stories from when she was alive. My favorite one was that when we originally decided to get a dog, I was mad because I wanted a cat. We went and found her at a farm where their dog just had a beagle litter, and Mandy first walked right up to my brother (who was around 7 at the time), and that was that. We were sitting in our family room watching a movie, and she was still a tiny, few month old puppy. I was sitting cross-legged next to the couch, and she came and crawled into my lap and promptly fell asleep. While she was an adorable puppy and I liked her up until then, that was the point when she stole my heart, that little rascal. I remember trying to stay perfectly still so that I didn’t wake her, so much that my legs fell asleep for 20 minutes before she finally woke up and trotted off.

I was always the one who played with her the most, and spent hours dragging her across the wooden floor playing tug of war, or throwing her the bone to go fetch. I also took to messing with her, and would frequently blow on her face (she hated that, which is weird because she loved her head being out the car window…), or trying to scare her from around a corner in our house, but it was all in good fun. We recalled the time we left out leftovers from Olive Garden on our kitchen table and walked away for 15 minutes, during which Mandy jumped on our kitchen table from the kitchen chairs and ate what was probably a pound of pasta and bread sticks. We found her in a food-coma. She loved to grab things out of the trash and run around with them just to make us mad. I’ll never forget how she would run around after baths like a mad dog, trying to tear up carpet and dry herself off. Or how she was afraid of the dog stairs we tried to buy her when she got too old to get on my mom’s bed. She howled at them and ran away.

We laughed, we cried, we picked out a silly urn to keep her ashes in. My mom seemed to be doing a little better, but it was still a sad moment. Mandy had shared 15 years of life with us, and despite how she probably loved food more than she loved us, we all loved her dearly. The final goodbye was sad, but it was something that we finally managed to do after over an hour. We all kissed her on the head and the vet tech wheeled her away, and that was the last moment I shared with my first dog. It chokes me up to think about it. I’m grateful for all the joy Mandy brought to our lives, and how I was lucky to have grown up with a furry little friend.

 

 

To this day, it is still hard for my mom to think about her, although it helps that she has my brother living with her at the moment. Mandy’s death made me realize how similar death is for humans and dogs. The phases of sadness, the sharing of fond memories, the laughter, how it brings a family together, and the final acceptance that they have passed. And at the end, it’s inevitable.

Death is going to happen to all of us, an experience that will be uniquely our own. It is scary, (hopefully) distant, yet it hovers over us all our lives. We turn to religion to cope with it, to drugs to forget about it, to books to try to understand it, to God to accept it. I am privileged to be able to share these moments with patients, their families, and their friends throughout my medical career. The act of simply being there, with a hug, a smile, or tears, is far from insignificant. I hope that I never stop crying at death, and that it never becomes too comfortable. To die is human. To love is human. I realize that am blessed to be able to guide and walk side-by-side as my patients go through this process, and it is something I will never take for granted. This is my reminder to my future self that even after countless hours in a hospital, after a 24+ hour shift, or whatever is going on, to always be there to sit and hold a hand. When it is my time to go, I hope someone returns the favor.

-Brandon

This week’s song is Yoshi City from Yung Lean, who pioneered “sad rap”

Here are some pictures of my dog Mandy from throughout her life. May she rest in peace.

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mandy-hat

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The last picture is shortly before her death in July 2016:

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