The Ethics Committee

This semester I have the privilege of serving as a student member of the Ethics Committee here at Mission Hospitals. As I have mentioned before, the eight of us are very lucky to have an ongoing Ethics course as part of this third year program. Most of what is learned about medical ethics is taught in the first two years at most schools (if at all), but these are the "pre-clinical" years. Why are we learning ethics at a time when we can't apply that knowledge? A concurrent course surely makes more sense to me. However, this program is one of the few that has that curriculum built into the clinical years. The eight of us get together monthly to discuss interesting cases, relevant issues (such as patient autonomy, end of life care, etc.), and delve into the inner med student animus. This is where we work out the numerous dilemmas we have seen or faced, so we are ready to meet these challenges in real-time later in our careers.

As part of the Ethics Committee, a few of us will participate in monthly meetings and (hopefully) be part of ethics consults in the hospital. Any employee can ask for an ethics consult (I believe), and the Chair, as well as a few other members, meet to discuss the case at the bedside. In March, we will be trained in "Ethics 101" to prepare for these encounters. I see myself as listening exclusively (I see you cringing when you think of me weighing in on ethical decisions...), but these are the experiences that can make me a better physician. These are delicate issues that can be handled with skill, or very poorly. I hope to learn how to do the former.

To get us started, the following case was found by our ethics professor, Dr. Meacham. It is taken from a recent report of the Hastings Center, a nonpartisan research institution for bioethics and public interest. In their latest edition (January-February 2012), this scenario was carefully considered. This, and other free articles, can be found at their website. While this case is not one that I have heard in a committee meeting, it is very similar to the type of cases that Mission deals with. Take a look today, and then I'll comment next week...

Mr. A arrives at the emergency department of Mercy Hospital, feeling run down and fatigued. He is a 35 year old African male who appears apprehensive and withdrawn. He says he is from Tanzania and that his first language is Swahili; however, he also speaks English. He tells the physician on call that he has headaches, no appetite, and nausea. He has also lost weight and his feet and hands are swollen. After numerous tests, the physician informs Mr. A that he has end-stage renal disease. 

End-stage renal disease is the final stage of chronic kidney, or renal, disease. It occurs when the kidneys are no longer able to function at the level needed for daily life - usually at less than 10 percent of normal. The most common causes of kidney disease in the U.S. are diabetes and high blood pressure. A person may have gradually worsening kidney function for 10-20 years or more before progressing to this final stage, but end-stage renal disease almost always follows chronic kidney disease. Patients who have reached this stage need dialysis or a kidney transplant to live. 

Mr. A's physician recommends immediate dialysis. However, Mr. A then tells the physician that he is in the U.S. illegally, that he has no family living in the area, and that he is unemployed. The physician consults a social worker, but he tells her that illegal immigrants are not eligible for any health care benefits. The physician is well aware that the Emergency Medical Treatment and Labor Act requires her hospital to not only examine Mr. A, but to provide him with any needed stabilizing treatment without considering his lack of insurance coverage or ability to pay. The needed treatment to stabilize Mr. A is dialysis. Therefore, the physician admits him and starts treatment. 

Following this, the social worker that Mr. A's physician spoke with tells the hospital administration that Mr. A has started dialysis and will need to continue indefinitely. Because he has no insurance and is an illegal immigrant, he is not eligible for any outpatient dialysis units. He is also unable to afford any medical treatments. Once Mr. A is stabilized, should he be discharged? He will need dialysis three times a week in order to stay stable. Will he have to be readmitted through the emergency room each time, or can he stay in the hospital until some other accommodations can be determined? Without dialysis or a kidney transplant - both which have serious risks and possible consequences - the buildup of fluids and waste products in his body will cause Mr. A's death. 

His physician and social worker turn to the hospital ethics committee for help. Given the situation, what should Mercy Hospital do?" 

Thoughts?

Ode to the Patient History

I walk in the room, we shake hands and you grin,
We sit down together, I tell you the position I'm in,
"Sir, I'm a student working with your doctor today,
And I have a few questions, if that is OK..."
I want to know how you are and what's wrong,
Where does it hurt? Has it been going on long?
I need to know if you have pain or can't breathe,
I promise to report all this to your doc when I leave.

Cuz you see, if I have the facts, I can make up a plan,
Present to my attending, and demonstrate that I can
Master the Art of Medicine, show her I'm tip-top,
Until we return to the room and you do a flip-flop!
If you say it's your chest, but now it's your back,
I didn't consider "triple A," and I'll hear so much flack,
She now thinks I didn't ask the right questions at all,
Because you changed your story while we talked in the hall!

See, if you'd mentioned your piercing and new onset pruritus,
I could've looked smart diagnosing nickel-contact dermatitis,
And you didn't say that you had a pet turtle named 'Bella,'
Suggesting your diarrhea might be from the bug Salmonella,
If you had told me you drink twenty beers in a week,
That your liver's cirrhotic, your breath's started to reek,
Then that would explain why you're sweating and shaking,
DTs are why you're sick and your body is aching!

So please (oh please!) just tell me the truth,
Tell me every pain that you have, from your toes to your tooth,
Tell me your story, and if you've been traveling of late,
Tell me if you have the clap after last Friday's blind date,
I won't tell a soul, 'cept your doc that's the law!
But please don't you stutter, don't you hem and don't haw.
If you don't want to see me, why don't you just say this?
So I don't end up looking like an unskilled ignoramus.

This is what I go through: my struggles and my pain,
"Now, please just remind me, Sir, I've forgotten your name..."

Saturday Night at Four in the Morning

I worked a 4 pm to 1 am Emergency Department shift last Saturday night, which is one of the unique requirements of this program. Most third year students do not do an independent Emergency Medicine clerkship in their 3rd year, so we are lucky to get this experience. The pace of this clinic is drastically different from Internal Medicine or Psychiatry. In the latter, I may spend an entire hour with a patient before presenting him or her to my attending, then we spend another 15-20 minutes talking to the patient together. In the ED, it's patient after patient after patient. Rapid fire. Where I might focus on "prevention" in other clinics, in the ED I always have to think, "What's going to kill this person right now?" Is it normal back pain or a ruptured abdominal aortic aneurysm? Are you having a heart attack or reflux? Is this a stroke or a migraine? The questions are different, and I have a short amount of time to get all the information (my attending will often enter the room before I've even gotten to the physical exam, because I'm taking too long to extrapolate all the salient info).

During this last shift, two of my patients were surgical candidates. I had a kid my age with presumed appendicitis, and an elderly lady with a perforated colon due to diverticular disease. As I was finishing up my shift, the surgeon on call met with both of these patients before taking them to the OR. Needless to say, I asked if I could join him as first assist, since I had worked up both patients with my ED attending. So, at one in the morning on a Saturday night, instead of being out and about or sleeping off a bottle of Chianti, I was back in the operating room. I'd spent a good bit of time on Ortho Trauma last semester, scrubbing in on cases throughout the year to keep up my skills, and every time I headed back to the OR I felt energized. While my energy had started to fade at around midnight in the ED, three hours later in the OR I again felt refreshed and ready. The sterile field, the bright lights, the calm. It was as if I had just gotten my 8 hours and I was up for another day.

What I've realized over the past few months is that not only do I enjoy the technical aspects of the OR, I also deeply care about working up the surgical patient. Understanding the underlying disease process, taking a full history and physical, and preparing for postoperative care are equally as enjoyable as holding a scalpel. I love all aspects of this type of care, and many of these patients are very, very sick. This lady with a ruptured colon had fecal contents all over her abdominal cavity - a life-threatening condition. Last July, I scrubbed in for a splenectomy (removal of someone's spleen - that funny little organ in the left upper quadrant of your belly), and I thought it was the coolest thing I had ever seen. I remember thinking, "Damn, I really can't see myself doing anything else. I have to do this some day." But, I thought the novelty of these surgeries would wane. What made the whole splenectomy experience that much better was rounding on the patient for two days before his operation, and then again for the next week post. I got to know the man as a person, even in a short amount of time, and developed an intense relationship. I enjoyed studying about his condition, understanding the pathophysiology, and caring for him after his surgery.

When we finished the appendectomy at around 4 am, I grabbed my bags and headed home. On the short drive back I was wired, ready for another case. I looked at the clock and realized that very few things in life are going to get me this revved up very early on a Sunday morning. As a physician, no matter what you do you will be up at four in the morning on a Saturday night at some point. Whether it's Surgery, Internal Medicine, Radiology, or whatever. There will be plenty of night calls, and plenty of overnight shifts. If I'm going to be woken up at 4 am, I want to be doing something that I love; I want to do something that excites me.

I know I have a long road ahead of me, but on that drive back, I thought, "Yes, I could do this."

Shaking Off the Rust...

This week was my first week back, and let's just say that I was a wee bit rusty. One would think that with only a two week break, I would be able to hop back into the old swing of things, picking up where I left off.  But it actually feels like I've taken a couple steps backwards. All that knowledge that's been building up over the past year? Gone. Well, not entirely, but I'm definitely a bit slow. Slow answering questions, slow remembering my physical exam, and slow moving about the clinic. Total slow motion. And after only TWO WEEKS! That's all it took! I can't imagine what a whole year off would do.

And that's a good question. Where will all this medical knowledge go if I take a year or a year and a half off? To me, that's the scariest thing about interrupting my medical education with a Masters. I know so many people who get their Masters in Public Health or do a year of research, and they come back just fine. They say it takes a little bit to get back into the groove, but by residency they are all ready to go. I guess I'm just worried about those first two or three rotations fourth year that actually count toward my residency application. These are called "Acting Internships" or AIs, and they are often done in the specialty of your choice. These are apparently where you meet members of the faculty in your specialty and get letters of recommendation, advice, etc. If I take a year off and then start back up with a surgical AI? No bueno. Especially considering I don't even know where the bathroom is in UNC Hospitals...

I always talk about how this year has gone by so fast, but in the next week or two we will meet about fourth year scheduling (yikes!). Unfortunately, I won't hear back from Masters programs until the end of March, which is the same time that our fourth year preferences are due. So I will have to apply for all my rotations next year without knowing whether I'll be in North Carolina or not. I would have loved to find out from schools first, but oh well. So, over the next few weeks, I will be choosing the specialties I want to spend a month in, while fulfilling all of UNC's requirements. I will have to do a month in surgical critical care most likely, as well as electives of my choice (like Radiology and Dermatology - both which I think would be extremely high yield). Half of school is planning ahead, and like my Mother always says, I was born with a life plan already in mind.

It's crazy to think that we are more than halfway through the Asheville program at this point. But, I can't meditate on this too long. Time to get back to work and shake off the rust!