DNR

So far I have been using this blog to discuss the different experiences that I've had an emergency room. It is really hard for me to write. I don't really like to sit and just type for a really long time. One day not too long ago, it was really slow at the emergency room, so I decided to set up an account on Dragon NaturallySpeaking just to play around with. After using it for a little while, I thought it might be a good idea to start using it to help me write my blog. So here we are, this is my first blog entry using Dragon.

A few weeks ago, I saw a very elderly woman with a lot of chronic conditions, who suffered a fall with serious fractures. Her family was there at the bedside, and of course they were very concerned for her livelihood. After my doctor discovered the fractures on the x-ray films, he went in to discuss the possibility for making the patient status DNR before surgery (the acronym for "do not resuscitate," often given to elderly people who no longer would like to be succumbed to the trauma of extreme life-saving measures.). since the daughter had power of attorney, he needed to ask her for permission to make her mother status DNR. I remember seeing the grief-stricken face of the daughter. She must have felt like she was being told to make a death sentence for her mother. Like any sane person, her first question was "well, what do you think I should do?"

And of course, the doctor did exactly what made sense. He said, "well, if it were my mom, I think I would want the doctors to do everything they can to keep her alive." To me, his answer made perfect sense for someone that was thinking on their feet, and was going with their gut reaction as a human being, and not necessarily as a professional.

it's funny that this event happened right in the middle right when I was reading the book, "how good do we have to be?" by Harold Kushner. I just read a chapter about the relationships between fathers and sons, mothers and daughters. There comes a point when the parents will die, and we as children will have a fear of letting go, especially if there is the possibility that we could be considered the responsible parties for their death. The author actually spoke about the exact situation where the child was asked by a doctor whether or not they would like to make their parent status DNR. The author argued that our first instinct is to make sure that others around us will accept us, instead of rejecting us. Perhaps the doctor's first instinct was one made out of fear of rejection, instead of being willing to make an opinion from a professional perspective.

The doctor's primary concern is the patient's well-being. with this in mind, his first thought was no doubt that the patient would perhaps find a higher quality of life status DNR instead of having to risk suffering through a traumatic experience of having chest compressions with the possibility of broken ribs, just to keep the heart from stopping. If this were the case, the author suggested that the doctor should respond to the patient's daughter by saying, "from a medical standpoint, we would like to make your mother DNR status, would that be all right with you?" This way, all of the blame will be placed on the medical professional, so that the daughter would feel more at ease with allowing her mother to pass on. Having a third party make the decision will look at matters objectively. Since this particular third party's perspective is from a doctor, it may have enough weight for the daughter to consider its worthiness as an option. Additionally, the daughter would be able to write off any guilt by blaming it on the doctor for making the decision.

What you guys think? To me, this is a very touchy subject. I have my hesitations for writing about it,but I would really like to encourage hearing other peoples opinions. This simply allows me to process the ways of handling very important relationships with other people

Reflections on the Med school interview process

I wanted to reflect on the last month leading up until my first interview for medical school, with the UW school of medicine. I have come to quite a few new realizations about myself, and the quality of my character in the process.

I have never prepared this much for an interview in my life! The most important factor was a seminar course I took called Presentation Dynamics. The course was about developing the skills of a 'natural' presenter. The end goal is to train me in what it means to present myself authentically in front of a room, whether in an interview setting or giving a formal presentation. The course lasted a whole weekend back in September, and reconvened just this past weekend. Fortunately for me, the course ended today, right BEFORE my med school interview this thursday!

I'm feeling so happy right now! I came out of the program sitting in an aura of clarity and positive feeling about my qualities that make me an effective presenter. I know what it is I have to do to portray myself accurately to my interviewers. The course encouraged me to do a lot of work on knowing myself as a presenter and how I create a relationship with my audience based on trust and mutual understanding.

I want to help people! I want to serve people because I love the process of healing through the development of a better understanding of our emotions. I am interested in medicine because I enjoy scientific research but need to have the healing element and human connection every day as well. In medicine, I will have the opportunity to use the skills I developed in a research environment to directly effect the outcomes of patients to heal. Being born and raised in a doctor household this is how I know to serve others. I know I will be a good doctor!

I can't wait to stand behind this in the interview.

The strengths I have as a presenter are mainly bravado, humor, confidence. From a practice interview I had in the program, I got the feedback that I frequently look down at the ground when answering questions instead of directly at people's eyes. From the same interview, they also told me I did not really seem 'grounded' in my answers, or coming at a conclusion from a place that is deeply true to me. This is most likely because I was not permitting myself to have bravado, humor, and confidence in a setting that seemed so formal and... touchy, I guess.

What I hope to do in the interview is get into the mindset that the best candidate I could be is exactly who I am as a person. I need to embrace that it is okay for me to be myself. If stop myself from 'going big' like what is so central to my personality, I will not come off as believable or trustworthy.

I'm feeling so clear right now. The mental state I have is what I hope I have at the time of interview. The state is 'unreasonable,' as in 'without reason,' as in, without making up any reasons to behave a specific way. This state is where I am grounded fully, there are no excuses for the ways that I react to people, and that's exactly where I want to be.

Medication-induced Psychosis

This patient was an elderly woman (in her 80's) who presented the ED with her daughter (in her 40's), who noticed an abrupt change in the patient's mental state while conversing with her that morning after returning from the grocery store. We suspected the patient had a TIA (transient ischemic attack, a mild form of a CVA, cerebrovascular accident, AKA stroke) because of the abrupt change in behavior that included slurred speech and 'word salad' with shortened misformed sentences. It turns out it was more likely to have been an adverse reaction to changes in her medication.

When we first saw the patient, things were going well; although the patient was not great at answering the questions, the daughter was a marvelous historian. It wasn't until Dr. Y had to leave the room due to a call from the EMS (emergency medical services, the ambulance drivers) that I noticed stress starting to surface. I stayed in the room to wait for the doctor's return and had the chance to witness the patient.

She began to perseverate short commanding sentences to her daughter that were obviously out of character: "Help." "Help me now." "Water." "Get water now." "What are you doing?" "Hurry" "Hurry now." It was obvious to me the abnormality of these sentences when the doctor returned and her mood once again became instantly compliant without complaint. Unfortunately, the daughter was greatly stressed by her mother's state.

20 minutes later, the patient gradually became more irate, and more violent, to the point where she was screaming wildly at the top of her lungs, "HELP ME! HELP ME PLEASE, NOW!" and when nurses and her daughter would attempt to calm her down, she would respond "GET OFF ME! LET GO OF ME, GO AWAY!" "AAAAAAHHHH!" We gave her ativan to calm her down, somehow that made things worse. She was constantly trying to escape and was highly agitated.

Imagine someone crying out very loudly in pain, fear, and anger for 40 minutes at the end of a 9-hour shift that started at 6am preceded by an 8-hour evening shift that ended at 11pm the day before. That was my situation. Imagine the situation for the nurses, who are coming off of much longer and more grueling shifts than I did!

I noticed so many emotions rising out of me and my coworkers. I could see obvious frustration, and agitation rubbing off on us all. People were angry at her for being so loud. I saw stressed faces, slumped shoulders, and distressed gaits when walking up and down the halls. No one wanted to deal with this lady, it was so stressful!

I remember how I felt that day: I was having so much fun working with this doctor because every day they are hungry to teach me something new and interested in who I am. Once that lady began to scream, I didn't want to talk to anyone. I didn't want to laugh at the situation because I knew how horrible it was for her daughter, watching her mother's deteriorated mental state in full expression. I was angry when I found out the new suspect diagnosis was she had an adverse reaction from accidentally crossing 2 medications. I felt like crap after my shift, not really wanting to go on a bike ride I had been looking forward to for so long because it meant doing something active. I wanted to lay down and go to sleep, wallow in some sort of self-generated self-pity.

It's pretty amazing to me how emotions and states of mind are so contagious. When someone isn't excited and happy, their state can easily plague the rest of the individuals in the surrounding area. When someone steps up and bursts out into an abnormally demonstration of happiness, like dancing on a bar table during a great song (which I'm guilty of doing in the past), everyone else tends to follow.

In a situation like the one in the ER, we frequently try to counteract these patients in severe distress by laughing at the audacity of the situation. It works at times, but with this patient's daughter there, I felt so distraught by the effects it was having on her. How would I feel if I was in the emergency room with my own mother who, just like a light switch, flipped into a mode of pure tantrum that is completely uncharacteristic of her? The situation was so scary and was an especially strong symbol of the transiency of the daughter's mother's life.

Theoretical reader, I'd like to ask you a question. Imagine you were in the middle of conversation with your parent and their mental status abruptly changed. While being taken care of by multiple strangers, she/he became severely agitated and began to thrash and yell violently for all to witness. How would you feel? What emotions would arise in you? What emotions arise in you RIGHT NOW?