Stony Brook University

First Impressions: I met a guy from Stony Brook at my RWJMS interview and had asked him back then what the program was like. He said there was more emphasis on clinical practice, less on research, but that it was a great program. I drove to Stony Brook the night before my interview accompanied by a classmate's fiancee, who was a PGY2 at Stony Brook and needed a ride back home. She was able to tell me where to go since my GPS was not working, and let me tell you, the night sight of NYC from the Verrazano Bridge was amazing.

Interview Day: It was snowing/raining as I drove to Stony Brook University Cancer Center, which seemed a bit bizarre for March. Incidentally I ran into the guy from RWJMS outside the entrance, and he said, "Welcome to Stony Brook." There were 5 of us total interviewing that day; two of which were from Stony Brook. The other two applicants I'd met at the Drexel interview just last week; both of them had interviewed at Jefferson (my next interview) just two days. We had a brief overview of the program from the PD before one of the fellows took us on a tour of the hospital. The hospital consisted of two round towers connected by a walkway; all the floors had a circular pattern. I immediately made note of the Starbucks on the ground floor ;) There was also a VA located about 30 min away where fellows do their continuity clinic (and have plenty of autonomy while doing so), but we didn't go there.

We had two interviews each today, and I think I got extremely lucky with my interviewers. The first was a breast cancer specialist not too far out of fellowship, so he was extremely easy to talk to. We chatted about breast cancer, non-fiction books dealing with medicine (i.e. the infamous House of God), medical TV shows, and more. My next interview was with an attending from the VA who also happened to be Taiwanese, so we talked briefly about places in Taiwan worth visiting. He made it clear that he wanted to know who I was as a person, not about how much reseach I've done (thank goodness), and asked questions about my life and my family. He took lots of notes about me, and when I told him why I wanted to specialize in heme onc (my mother was a breast cancer survivor), he looked impressed and said he would like to see me here next year. O.O That is the most positive feedback I have ever received at any interview.

Overall Impression:
Pros: Good balance in both heme and onc, diverse pathology throughout Long Island, 3 fellows a year. Autonomy in decision making and patient care at the VA. Emphasis on clinical training. Friendly fellows and attendings. Located 1 hr away from NYC and JFK International Airport. Long Island known to have famous beaches and diverse outdoor life.
Cons: Stony Brook seems a bit isolated, surrounded by small suburbs. Still, there are Starbucks, Barnes and Noble, and even a Cheesecake Factory nearby, so it can't be too bad.

Trying to Die

In residency I've been a relatively white cloud, and so far my MICU calls have never been overwhelmingly busy. That's not to say, however, that the patients on my census are well. My GI bleed from two calls ago was still on 4 pressors and officially in multi-organ failure, so finally his family withdrew care and allowed him to pass on. I was sad about that; this man came into the ED one week ago for a lower GI bleed which was fixed, but for some unknown reason he went into vasodilatory shock afterwards. He himself had given consent to be intubated after he coughed up bright red blood, believing that after the EGD he'd be extubated. Sadly he didn't make it.

Last night I was able to sleep for about 45 minutes before midnight before my fellow called and said there was a multi-drug overdose in the ED. The patient was a young man close to my age who attempted suicide by swallowing TCAs, an entire bottle of aspirin, and some Tylenol. When I got downstairs, he was undergoing gastric lavage and the ER was trying to get ahold of nephrology for immediate dialysis. The reason being was that despite taking tons of TCAs (which would make him dry), he was diaphoretic, indicating aspirin toxicity. His initial labs, however, showed normal levels of the drug and no signs of lactic acidosis, and the nephrology fellow argued that based on the current labs she had no reason to emergently dialyze this patient. Both the ER attending and toxicologist insisted that this was a life threatening overdose and that the patient would die without HD. This was the first time I ever perceived relations between the emergency department and medicine department to be hostile (though the attending was more welcoming toward me and my fellow, since we'd be taking the patient to the ICU), but I could see where the ED people were coming from.

Just a few months ago, a patient died from a metformin overdose because his labs on admission were "normal" and he was sent to a step-down unit instead of the ICU. By the time he made it to the ICU until his pH was already 7.1 and his bicarb was in the single digits. Almost every department in the hospital attended the M&M that followed his death, and the conclusions we came to was that presenting labs can be deceiving, and that we need to anticipate the progression of the toxicity of any drug overdose. If "Metformin Man" had received bicarb and emergent dialysis on admission, he probably would have lived. And now looking at this TCA/ASA overdose, I couldn't help but remember what had happened to the Metformin Man, and I hoped that we would be able to save this patient.

Fortunately repeat labs showed that the aspirin level had tripled, providing the nephrology fellow with a reason to start HD. HD was started 3 hrs after admission, and he was put on IV Mucomyst and a bicarb drip. I got my first truly successful A-line in him. By mid morning his drug levels were trending down and his labs remained stable, so I'm hoping he does all right. What saddened us was the reason behind his drug overdose: he didn't match for residency last week =/

Drexel University College of Medicine/Hahnemann University Hospital

First Impressions: Ahh...good old HUH. A common question I've gotten on the interview trail is why I came all the way to Philly to do my residency instead of staying in TX. I'd had my best interview here, and the camaraderie among the residents and faculty really appealed to me, so I ranked the program high on my list. I have no regrets about my decision to go out of state for residency, as I've made many friends here and have grown to love living on the East Coast.

Knowing from day 1 that I wanted to apply to heme-onc, I immediately went about making myself known. I did inpatient heme-onc floors at both HUH and the "Bing," selected heme-onc electives, and started doing a secondary clinic this year at the outpatient heme-onc office. All the attendings knew me and, for the most part, knew my work ethic and personality. I was told that HUH likes to takes its own applicants for heme-onc, and hopefully that's still the case.

Interview Day: All interviews are held on a Saturday, which was good and bad (good being that I didn't have to take a day off from work to interview, bad in that you don't see as much on the weekends). There were about 12 of us, and of those 12 only I was from HUH. That was a mistake on the program's part; usually they interview all HUH applicants early in the season but somehow my file got overlooked and they had to squeeze me in at a later date. The program director gave a very straightforward powerpoint presentation describing the fellowship in detail, and then three attendings took turns interviewing us. They saved me for last since they knew me already, but in the meantime two fellows came to chat with us about the program. One of the fellows I knew well, since I was helping him on a Phase II project earlier in the year, and the other was surprised to see me since he didn't know I was applying heme-onc. My interviews were extremely laid back; the first one was with an attending I knew well and we talked about patients I was currently seeing in the ICU. She also asked me what games I had on my iPhone, so I gave a brief demonstration of how to play "Angry Birds." It was fun at the time, but after I left her office I thought, "What just happened?" Not your everyday interview. They told me I didn't have to meet with the program director b/c he wrote my rec letter, but I sat down with him anyway for about 10 minutes to update him on what has been happening with me.

This program has a university name but runs more like a community program. There are no specialists in any particular organ system; all the attendings here are "general oncologists" who see all types of malignancies. The clinics, also, are combined so there is no "breast clinic" or "lung clinic;" you see all types on any given day.

Overall Impression:
Pros: Good balance in both heme and onc, diverse pathology, 3 fellows a year. Having been here for the past 20 months, I am very familiar with the archaic computer system and how the inpatient, outpatient, and consult services work. Philly is a pretty good place to live (2 hrs from NY, 2.5 hrs from DC), most rotations done at HUH except electives at other hospitals. Good relationship with the attendings, very hopeful that I'll be ranked high.
Cons: No subspecialists within hematology/oncology; this program tends to produce general oncologists going into private practice.

Futile

I am currently doing my ICU month, which I have been dreading for ages. To put it bluntly, I do not like critical care. I have never been good at thinking on my feet and dealing with stress. The ICU attendings, thank goodness, are all good people who aim to teach and not criticize. Even when I forgot to lavage a guy bleeding from his rectum (it turned out he had bleeding duodenal ulcers as well), the attending just said that I didn't work up the patient well enough. No blame, no yelling. I still felt awful afterwards and blamed myself for not being thorough (even though my fellow residents thought I was making too much out of it), but it felt better knowing that despite my poor intensive care skills, I still had the support of my friends and attendings.

Currently there are about 24 patients in the ICU, and 4 of my 5 patients were complete trainwrecks. First is the GI bleeder mentioned above; he was scoped from both ends with no evidence of bleeding (just a few superficial orders), and then he had another giant maroon BM and needed another emergent endoscopy that revealed vessels in 2 ulcers that were clipped. Hopefully that'll be the end of that. Another is a man with ESLD, partial SBO, and the worst respiratory drive I've ever seen. Sometimes he became hypoxic, othertimes he was tachypneic in the 30s, and we couldn't change the vent fast enough to keep up with him. His ABGs were slightly on the acidotic side but uncorrectable with vent settings; getting good ABGs on him was a nightmare. Another ESRD guy practically looks like a skeleton and has self-extubated himself twice since I've been on this service (each time needing to reintubated again), and his wife won't make him DNR despite his poor prognosis.

Then there's my lone female patient, a woman in her 50s who presented with a 6-month history of intractable cough and ended up requiring intubation (and later trach) due to hypoxia. She had multiple lung nodules on CT and a pleural fluid biopsy revealed lung adenocarcinoma. There was a time where she was completely obtunded and people feared she'd never wake up. She started stirring when I started the service, and now she's wide awake. Despite our best efforts, however, we have never been able to wean her off the vent. She has continued to have coughing fits while trached, and this comes out in loud gasping cries that can be heard throughout the center part of the ICU. Sometimes she's able to speak through the vent and say, "Help me." We can all hear her, and it's absolutely heartbreaking. It seems that if she can speak, she should be able to make it off the vent, but she gets so agitated all the time that she becomes tachypneic and weaning becomes impossible. I don't know how to help her. She's allergic to codeine and can't take Tessalon through her Dobbhoff, and the Robitussen isn't touching her gag reflex at all. I know that it's impossible to cure everyone in the ICU, but I feel like we're prolonging her suffering.

Sometimes I wonder how people can go into pulm/crit without being completely drained. I've been on service for 9 days straight (black weekend), and I'm already tired and frustrated that I can't help my patients get better. Sad thing is, with the exception of my GI bleeder, the other three are going to be with me until they either die or go to hospice. There is no getting better. And that's the worst part of this job.

RWJMS - Cancer Institute of New Jersey

First Impressions: I could have easily driven to New Brunswick (about 90 min from Philly) the morning of my interview, but since I was post-call the day before I just decided to spend the night in New Brunswick. Home to Rutgers University (the equivalent of UT in TX), New Brunswick is essentially a college town, and the hospital sits right on the edge of the Rutgers campus. They had a few places that sold boba tea on campus so I got one after dinner. It was all right; better than Philly's boba tea, at any rate.
Interview Day: There were six applicants today, one of which was from Univ of Rochester where one of my best friends is doing her residency (small world). The program directors gave us a good overview of what the program has to offer (a lot), and then the six of us took turns interviewing with four faculty members. I think because we were a small group, we found it easy to chat between interviews, and we also shared our experiences interviewing at other hospitals. Two of the applicants just had their Montefiore interviews yesterday, and it was interesting to note that their interview day there was just as awkward and poorly planned as mine was. We each interviewed with two hematologists and two oncologists; I think I got along great with the oncologists, but the hematologists were a bit harder to connect with because I've had almost no heme experience in residency (the attendings at HUH are primarily solid tumor oncologists)

This program is a good one in that it's balanced in both heme and onc training, and it's affiliated with the Cancer Institute of New Jersey, one of only 40 NCI comprehensive canter centers in the nation. That means excellent resources for research and training. The program also has programs in Phase I trials, stem cell transplants, and even special centers for hemophiliacs and thromboses (which I'd never heard of until today), which I all found interesting. We had 1-2 fellows come to speak with us during lunch, one of whom used to be a chief resident at RWJMS so she knew all the ins and outs of the program. One thing she emphasized was the close relationship between faculty members and fellows; the fellows never have to worry about getting yelled at when they have to call an attending at 4 a.m. to go over a patient.

Overall Impression:
Pros: Good balance in both heme and onc, association with CINJ means lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, cancer center on site, plenty of research opportunities in either clinical or laboratory settings. 4 fellows a year. 90 minutes from Philly, 45 minutes to NY. Most rotations done on site except for clinic on Jersey Shore one month a year. Will rank high for sure
Cons: None that I can think of at the moment.

Albert Einstein-Montefiore Medical Center

First Impressions: The name "Montefiore," aka "Monte," is a good one on the East Coast, as it has strong residency and fellowship programs well known for preparing its graduates for anything (my ICU attending used to be at Monte and he's one of the smartest people I've ever met). One of the PGY3's in my program matched here and will start in July, and I looked forward to seeing what kind of program this was.

Since I had taken a day off after getting stranded in Charlotte overnight (see previous post), I was able to leave Philly at 1 pm. (after taking a 3 hr nap) and arrive in the Bronx by 3:30 pm. The Days Inn I stayed at was a 1/2 mile walk to the subway, which I took to the NYU area for my usually trip to get Pinkberry frozen yogurt. Walking back to the hotel at night, however, was a pretty terrifying experience; the Bronx is not exactly the safest part of NY. My biggest gripe with my hotel room was that it smelled faintly of urine. Ugh.
Pre-Interview dinner: None. I had dinner at Saint Alps, a Hong-Kong/Taiwanese cafe that serves delicious boba tea (which I can't get in Philly)
Interview Day: The drive to Montefiore Medical Center was, fortunately, not a bad one. My first impression of the hospital was that it was old, even more decrepit than JPS (which looked great by comparison). There were about 11 of us at the interview, and each of us would interview with both program directors. So the entire morning consisted of the two interviews, or else waiting for the interviews. Very poorly organized. There were 1-2 fellows who came to speak to us but that was it. We were not a talkative bunch, either; most of our downtime was spent on our smartphones checking email or sending texts. I did learn that I got another interview during this time (at my home institution), so thank goodness I got my iPhone. My interviews were not the greatest; one PD asked me about research I did in 2003, and the other asked how I'd work up a patient for leukocytosis. Not the best time to ask considering my computer was in the shop (got a Trojan) and I hadn't had time to review my application.

After a brief tour of the hospital (gloomy), we had to take a shuttle to the research campus of Albert Einstein Medical Center for lunch and a brief talk about the research opportunities here. We couldn't all fit in the shuttle so some had to take the taxi. We didn't eat until 1:30 pm, and then we went to a lecture about some of the projects that were being done here. Even THAT was cut short because we then had to take a shuttle back to Montefiore. And by the time I got to the parking garage, some idiot had parallel parked his car behind mine. Thank goodness someone was there to move the car, but I saw that there were other cars parked similarly within the garage b/c there were no more spots yet. Talk about inconsiderate! (then again, this is New York). Bronx traffic was horrible too; I was glad when I crossed the bridge into New Jersey.
Overall Impression:
Pros: Very strong program in both academics and research. Well balanced in hematology and oncology. Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, plenty of research opportunities in either clinical or laboratory settings. 8 fellows a year, subsidized fellow housing, reasonable parking prices (for those who keep their car, which I would like to do), a 20 min train ride to Manhattan.
Cons: Way too much emphasis on research, fellows rotate through 3 different hospitals, unable to gauge whether fellows are truly happy to be there. Bronx isn't the safest place to live; not completely sold on living in NY, as cost of living is ridiculously high. Program did a poor job of selling the program.

University of Florida @ Gainesville

First Impressions: I got my first invite from this program in early January, and there are lots of good things to be said about UF. Shands, its teaching hospital, is ranked 29th in the nation in cancer care, and they have a brand new cancer center that just opened in 2009. It's also somewhat associated with Moffitt Cancer Center, one of the top cancer centers in the nation located in Tampa.

Gainesville has a tiny airport with only 3-4 gates (impossible to get lost); I had to catch a connecting flight in Charlotte to get there. I rented a car for the interview, and as I drove through Gainesville, it was hard to complain about the 70 degree weather and palm trees lining the streets. The hospital was located right beside the undergraduate campus of UF; truly a college town.
Pre-Interview dinner: I met the 2 program directors (who are both very young; if I hadn't seen the PD's face on the website I would have mistaken him for a fellow, and some of the applicants did think he was a fellow) and other applicants at the hospital before we carpooled to an Asian fusion restaurant called Liquid Ginger (or "Liquid G" as one of my interviewers would refer to it). There was a lot of good food on the menu, everything from steak to pad thai. I didn't want to cost the PD too much money, however, and so avoided the ribeye and got a shrimp and scallop dish that was really good. I met another applicant from UTHSC who knew a few people I'd known from undergrad; small world. Dessert was red bean ice cream. It was a nice relaxed dinner, and I didn't feel quite so nervous about the upcoming interview.
Interview Day:
The PDs welcomed us to the program and gave a very informative powerpoint presentation about what UF had to offer. My first interview was at the VA across the street with a head-and-neck specialist who was interested in hearing about a project I was doing on head-and-neck cancer. It was slightly embarrassing when I didn't know what the side effects of cetuximab were (despite it being used in the project), but he didn't make me feel like an idiot. After that we toured the new Cancer Center and the VA, also checking out "Fellow Land" (where the fellows have cubicles and computers). Lunch was with the fellows, and then we walked almost across campus to the outpatient clinics. There was a LOT of walking to be done on this day, and I wasn't wearing the most comfortable shoes either. I ended up going across the street to the VA three times (twice for interviews), and in the afternoon it was hot and humid outside. My second interview went very well, I thought; the attending was interested in topics such as breast cancer, patient-doctor relations, and palliative care, all of which I could talk about for a LONG time. If anything can get me into this program, it was this interview.

I wish I could say that after that interview I was able to fly safely back to Philly, but things didn't happen that way. My flight from Gainesville to Charlotte was delayed 1.5 hrs because of a storm in the Carolinas and Georgia, and even then we flew for 2 hours instead of 1 b/c the pilot made a wide detour to Alabama to avoid the storm. By the time we landed in Charlotte, my flight to Philly had already departed (missed it by less than 30 minutes). Needless to say there were tons of people stranded at the airport because of missed connection flights. I went to the Special Service line and was able to get a seat on the 6:30 a.m. flight back to Philly the following day, but then I hit another problem: lodging. Just about every hotel in the vicinity was completely booked due to people missing their flights, except for a Westin with rooms starting at $319. Since it was midnight anyway, I decided to suck it up and try to get some rest in the airport. In a way I felt like I was on call minus the beeping pager. All I'd had for dinner was Cheerios at Gainesville and all the restaurants were closed; fortunately a Starbucks stayed open just for us and I got a smoothie and muffin to sustain me until morning. With the help of my travel pillow, backpack (for back support) and fleece-lined ski jacket, I managed to get somewhat comfortable in a chair and slept on and off until 4:45 a.m. I boarded the plane at 6 a.m. and was back in Philly by 8 a.m, after which I slept 3 hrs before driving to New York for my next interview.
Overall Impression:
Pros: Really liked this program. Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, new cancer center, plenty of research opportunities in either clinical or laboratory settings. 5 fellows a year, PDs friendly and approachable, personalized training with different tracks (i.e. more research electives for those interested in academia, more clinical electives for those interested in clinical practice), strong in both solid tumors and hematology, affordable living in Gainesville, guaranteed good boba drinks in Gainesville (found a Lollicup cafe not far from the hospital). Florida. Sunshine.
Cons: Gainesville is not easily accessible by plane; most major airlines fly to nearby cities Orlando and Jacksonville and people drive to Gainesville from there. Chances of getting in are very slim given UF's history for taking their own residents into their fellowships; both PDs did medical school, residency, and fellowship at UF, and the same could be said for some of their fellows. All that aside I definitely plan to rank this program high.

Penn State Hershey Medical Center

First Impressions: I was supposed to have had this interview last month, but a huge snowstorm had forced me to reschedule. Several residents told me that the fellows at Penn State work really hard but get an excellent education, so I was pretty sure the program itself was excellent. I'd heard that Hershey was in the middle of nowhere, but it was still a surprise to see how isolated it was when I drove there after work. It was dark, and there were barely any lights to be seen except from the lone farmhouse. I kept looking for a cluster of lights to show that I was in town; no such luck, as there was a single-lane road (appropriately named "Chocolate Ave") that led to the hotel. I did grab dinner at a small hole-in-the-wall sushi restaurant that was actually pretty good; got a chef's special (California roll topped with salmon and shredded lemon). I'd booked a cheap hotel room for the night, which was a bit of a let-down since the last hotel I'd slept in was the Gaylord National, but safe enough. My only complaint was that the room was cold despite the heater being on, and I'd forgotten about how I never sleep well the night before interviews. Woke up around 3 a.m., couldn't really sleep after that.
Pre-Interview dinner: None
Interview Day: No traffic getting to PSHMC, and parking was free. There were eight applicants today, one of whom was the sister of one of my classmates. Most of us were from PA. We sat in on grand rounds with the topic of the day being hormone therapy for breast cancer (a particular interest of mine so I paid very close attention), then had the program director spend about 45 min telling us about the program and the hospital itself. The PD was very charismatic and energetic; it was obvious he loved what he did and took pride in the program.

I had three interviews: one with the chief of heme/onc, one with a leader in BMT, and a rad onc attending. Unfortunately for me, the chief and I didn't seem to connect very well. He had only been at the program for a year and was formerly from UPenn (that alone probably counted against me), and his specialty was translational research. Not surprisingly a lot of his questions were directed about future research I'd like to do (rather than research I'm doing now and would have been very happy to tell him about), and he ended up doing most of the talking. I'm not even sure how much he wanted to conduct this interview; we'd already started 5 minutes late because he was working on other things up until the last minute. My second interview with the BMT attending was a little better; he actually knew the former TCOM dean from their days at PSHMC and asked if I knew where Dr. MH was now. I didn't know the answer then, but since I got home I looked him up and found that he's now the dean at UNECOM in Maine. *sigh* I guess now we'll be seeing UNECOM rise in US World News Report in the next few years.

After the first two interviews we went to breast conference and then had lunch. My last interview was supposed to be with a GI attending who just happened to be on service, so they gave my file to a rad onc attending who doesn't even deal with the heme/oncs much since his focus is XRT in GU/gyn malignancies. He, too, was a fairly new attending, so we chatted instead about his transition from Cleveland to Hershey (i.e. learning to adjust to small town life), where to buy organic food (1 hr drive from Hershey!) and more. After that we had a tour of the hospital with two third-year-fellows who were fun to talk to. One of the best things about this place is the fellows' cubicles; large windows, plenty of light and computers, just no privacy. We also learned that fellows only round on the BMT service on weekends (and units); the onc inpatients are cared for by housestaff. That's good since at HUH the weekend fellows round on EVERYONE, even the inpatients.

Overall Impression:
Pros: Lots of diverse pathology, specialists within each department (breast, lung, colorectal, heme, etc) for focused treatment and care, brand new cancer center, plenty of research opportunities in either clinical or laboratory settings. 3 fellows a year. Harrisburg about 20 minutes away, Philadelphia 1 hr away by train (1.5 hr by car)
Cons: Hershey. Small rural town, lonely place to live if you're not married with children. Emphasis on research and academic careers.

Too Young to Die

Heart failure...one of the most dreaded services in this hospital. It's not so much the patient load (which was usually less than six patients per team) or the numerous medical problems the patients had, but fear of the attendings. The two heart failure attendings expect a great deal from us and we are expected to know every single cardiac detail about them. To make a single mistake on this service is to fear for your license, even for something like giving a heart transplant patient Percocet. Fortunately the two heart failure teams work together as one. My sister resident and I get along great, and the two interns called each other their "work spouses" to provide emotional and friendly support. It wasn't uncommon to see all four of us getting breakfast in the cafeteria or chatting in the lounge. But because heart failure patients are so sick, they often come to the hospital over and over, and inevitably they will die after we've gotten to know them.

A few months ago, a 19-year-old boy named N.L. was playing basketball when he gradually became weaker and suddenly collapsed in the middle of the game. His CPK was through the roof so it was believed he had rhabdo, but a high CPK did not explain his EF of 30%. A heart biopsy revealed that he had a genetic marker for some sort of X-linked muscular dystrophy, which was odd because most patients with muscular dystrophy exhibit symptoms as children, not young adults. And even though it was not the correct diagnosis, the unofficial diagnosis for his condition was called Duchenne's (DMD) by almost everyone. The first time I saw this guy 3 weeks ago, his EF had already plummeted to 15%, but both he and his mother remained hopeful that with medications they could control the progression of his heart disease. He was a college student, and he was anxious to get back to his studies.

This morning my intern called me and asked, "Do you remember N.L.?" Of course; how many 19-year-olds with so-called DMD were there on the heart failure service? I just didn't know he got readmitted last night. Then my intern said, "He just coded upstairs so I'm helping the other team out." WHAT? I quickly ran up to the tele floor and saw that N.L. had been transferred down the hall to the CCU. The CCU team was working on him, giving compressions, trying to put a central line in him. He had been on the other heart failure service the last time he was here, and the intern who had taken care of him looked extremely shook up. To say he was upset was an understatement; the poor boy was crying and wiping his eyes while trying to maintain his composure. He was on call overnight and had admitted N.L. for hypoxia (likely another sign of progression of his DMD), but no one had expected this.

The code (which I did not participate in since the CCU team was running it) lasted almost 90 minutes, but not surprisingly (ABG had pH of 7 and lactate of 10) N.L. didn't make it and died at 8:30 a.m. There was an extremely somber air on the tele floor for the next 3-4 hrs. Everyone kept talking about how young he was, only 19 years old. "At least it was quick," my attending, who was in his 70s, commented; having seen examples of prolonged suffering in the ICU/CCU setting, I had to agree. The CCU resident came by to offer support to the heart failure intern, then pulled his resident aside and asked her to let him go home. Fortunately she did; that poor guy only got 2 hrs of sleep last night and then to lose a well-acquainted patient on the last day of his heart failure month...I can only imagine how bad he needed to get away and get some rest.

Seeing this intern mourn the loss of his patient reminded me just how much the interns still have to learn about dealing with death at the hospital. I can still remember my intern from July expressing shock when I told him we wouldn't be doing anything for a DNR/DNI patient in respiratory distress except putting him on oxygen and a morphine drip. "That's it? We're just going to let him die?" he'd asked at the time. Sadly, no matter how many people we see die in the hospital, dealing with it never gets easier.

Time of Death

When I was on call two days ago, my cards fellow called me to say there was an eval in the ED and could I please go downstairs to assess the patient. The only information I had was that he was just discharged 1 hr ago after a 2-day stay s/p BiVICD upgrade, and not long after he left the hospital, he suddenly became unresponsive and his wife immediately drove him back. He arrived pulseless and in V-tach; a shock of 200J pushed him into PEA and it was only with epi that he regained his pulse. The ED residents were putting a central line in him by the time I got down, with the attending planning to initiate the "Arctic Sun" protocol, also known as hypothermic therapy. Studies have shown that if a patient's body temperature is cooled to 33 degrees Celsius for 24 hrs after a cardiac arrest, then rewarmed after 6 hrs, s/he is less likely to have long-lasting neurologic damage. I had seen this method used at the JPS ICU, and this was the first time I'd seen it done here. Once the patient got up to the CCU, they placed cooling pads on him and proceeded to lower his temperature. Then he went into another sustained run of V-tach and I, as the most senior resident in the unit, had to decide whether or not to shock the patient. This was the closest I've ever come to running a code and I was terrified (even though I didn't show it), and I told them to administer the shock. It fixed his rhythm but only temporarily; it took 150 mg of amio to get him back to his baseline A-fib. Even still, I called my fellow and asked him to come to the hospital to help me out. We ended up putting A-lines in my two patients (I got my first successful A-line that night), but they were such hard sticks that we went through 10 A-line kits before we got the lines in successfully (not joking).

The next morning (yesterday) the patient's cardiologist came in to see what had happened. He told us that the patient had a history of cardiac amyloidosis that caused him to have diastolic dysfunction and increasing episodes of V-tach (they'd attempted an AV junction ablation during his last admission but it was unsuccessful). We also learned that his ICD had shocked him twice while he was in the car, but it wasn't enough to correct his V-tach. The patient's wife stayed with him and requested that we call his PCP, who was a prominent figure in the medicine program. He later came to see the patient and spoke to the family at length about the patient's overall prognosis. It also came to light that the patient wanted to be DNR/DNI, and the family agreed that once the patient was brought out of hypothermia, if he didn't regain consciousness, then they would withdraw care.

This morning the patient continued to be unresponsive and comatose even after the Arctic Sun was turned off. The patient's PCP, gastroenterologist, and EP physician all stopped by in the morning to speak to the family and offer their condolences. When all the family members had gathered, they requested that we withdraw care as they didn't want to "draw things out." The end came pretty quickly after he was extubated and the pressors turned off. We left the room but kept an eye on the tele monitor, watching his blood pressure dip lower and lower while his heart raced in V-tach in an attempt to keep his BP up. Less than five minutes later, I was in the room pronouncing the patient dead while his family members held each other and cried.

It had been a good year since I'd had to declare anyone dead, but fortunately I remembered the steps and was able to fill out the death packet and make the necessary phone calls. *sigh* And here I'd hoped to go through this rotation without ever having to fill out a death packet. In this case, however, I'm glad that the patient had made his wishes known and that his family had honored his wishes. Too many times have I dealt with families who could only think about what THEY wanted and not what's in the patient's best interests. I have yet another patient who's comatose after a PEA code, and even though it's been two weeks his wife has YET to find his living will. She says she'll bring it tomorrow; we'll see.