My classmate Sundance - yes, the Sundance I’ve interviewed twice on video - recently shared with me a letter to her family about her inpatient rotation. She was kind enough to give me permission to publish it, and I’m sure you’ll see, as I did, what a great insider’s perspective it is*. As with everything Sunny does, it has childlike wonderment, artistry, and astute observation.
I hope you like it. -P
Hello family,
I know it seems nothing new that I am on “another killer rotation,” but this one is blowing my mind.
Even with the excitement of the ER — patients coming in with new stroke signs, hearts sending blood into new spaces, or the HIV clinic, where AIDS is made more complicated by depression, drug addiction, homelessness, etc. — my very few days in the ICU showed me the sickest patients I have ever seen.
The ICU, or Intensive Care Unit, is a special floor at Cline Memorial Medical Center. It’s ground zero for God-battling. Death has a lot of machinery to claw through here to take a life, and rarely does it win (for better or worse).
One day I even asked, “Where do people go to die? Do they die here?”
“Not usually,” a kind, baby-faced, coo-mannered young nurse named Josh told me. He had the tone of hesitant confidence that the most capable, competent, and insanely smart people have. Like Josh, they are often nurses. “Depending on the wishes of the family, they either go home, go to a normal hospital bed, or go back to the Skilled Nursing Facility.”
Death does not win here.
Which brings me to the sickest person I ever saw, a 63-year-old woman. Young, I know. I first noticed her snoring respirations at 7 AM, while gathering information on another patient with a triple coronary artery bypass. During rounds, Josh (cool as ever) began describing the patient’s story to the intensivist (critical care doctor) in a gentle tone that didn’t fit his words. Each point was the sickest, saddest, shocking-est thing I had heard in my years of training. The list went on and on.
“She has renal failure requiring dialysis, pneumonia with empyema (lung full of puss), UTI, diarrhea, septic shock, hypotension, elevated INR.”
The high INR meant that she had little ability to clot and could therefore bleed like crazy. She was DNR/DNI (orders for no CPR, no breathing tube) and her infection had her so out of it that she couldn’t hold her jaw up to breathe. The challenge to the team was figuring out where her sepsis was coming from.
Sepsis is a life threatening, total-body infection. It could be coming from her lung. It could it be coming from the pressure ulcer on her back that looked like a tennis-ball-sized crater revealing her spine. Or maybe her PIC line (an IV tube into a big vein) that had been in place for far too long (weeks, instead of days). Was it harboring infectious bacteria? Or was it her diarrhea, which continued to flow from her rectal tube?
The woman, when we examined her, was not there. Whether it was the multiple infection sites or the fact that she was nearly suffocating, she was non-responsive, even to pain. Her body was a strange sight: legs gone below the knees (the classic kiss of diabetes), abdomen and arms a strange deflated mass of amorphous tissue left over from an obese habitus. She looked like she was dissolving, melting away from the bottom up. The smell of her dinner-plate sized bed sore made me grit my teeth. I was grateful for my sterile gown and mask, and wished the mask was thicker and my stomach stronger.
As we finished up, like weird blue aliens in plastic protective gear, I backed away, done with this “almost person,” and hid my inner battle. My blue plastic body was present, helpful, involved, and attentive. But my mind was falling down Alice’s rabbit hole. How could she still be alive? How could this be okay with her family? How could so many things be going wrong with the body but the heart still be beating?
All I could do was exit the room, tear off my gown, wash my hands, put my short white coat and stethoscope back on, and say - almost to anoint myself - “That is the sickest person I have ever seen.”
She will be there tomorrow too. Unbelievable.
Sundance
Post script: Clostridium difficile was cultured from her stool, and was probably the cause of her new septic presentation. Big-daddy antibiotics were started. She was put on a Bi-PAP machine to force air into her lungs without a breathing tube, and she awoke enough to struggle with her mask. Plans were made with the family to move her to “comfort care,” a way of discontinuing intervention and making her comfortable in preparation for a peaceful death.
In the intensivist’s words (insert heavy Indian accent here), “Her day must have not come, for she is still here.”
*Identifying information in this post was changed to protect the patient's privacy.
[subscribe2]
I can’t tell you enough how impactful it is to read these first hand encounters. Paul, I really enjoyed the overview of your EM rotations as well. Thank SOOOO much for continuing to put this ‘1st person view’ material in the hands of your many followers… especially since we know you don’t have time to give us even “weak” material due to your ruthless end of clinical year responsibilities.
I sincerely appreciate the effort you put forth on our account!
JD
Thanks for your kind words, JD. Hopefully I’ll have more time soon. Either way, Sundance is a real gem.
Good post, Sundance! I enjoyed your real perspective and hearing your experience. Good stuff. Thanks for sharing.
Wow, how humbling, as an EMT we barely get as in depth as this and it’s interesting to see just how these diseases affect the patient. It is really amazing the difference medical interventions can make.
First off, thank you Paul for this amazing website, I Love it!! Second, thanks for sharing this letter from Sundance. I really enjoy her enthusiasm! As a Respiratory Therapist, I really enjoy getting to learn things when I can, however my time can be so limited while at work along with the many patients assigned to me. I have a long while before I can apply for PA school, so thanks again for this site. I will continue to visit, things like this keep me looking forward to what’s in store!
Hi Paul!
Thank you so much for this resourceful and very informative website. I am currently in my freshman year of college and I am considering a career as a Physician Assistant. I was thinking about getting a bachelors in nursing at the community college that I attend, but first an AS to become an RN. The RN program is an accelerated program, as it only takes 2 years to complete. After reading a few forums about the cons of nursing(specifically RN) and the horrific descriptions of some of the day to day tasks involving fecal matter and terrible smells, I’ve decided that RN is a no go for me. I also read your comment on another post that stated that using a career as an RN as a stepping stone to the PA profession was a bad idea. I was hoping you could let me know some of the cons of being a PA. I read one of your posts that covered this but I guess what I’d really like to know is if I’ll have to care for patients in that way(changing diapers, cleaning bacteria from folds of skin, smelling nasty smells, repositioning obese people, etc.) I just don’t want to go head on into this field of work to be in store for a rude awakening. I love to help people and have volunteered at a retired living facility in the past, so I hope my question doesn’t make you think otherwise. Thank you in advance.
Great question, Emma.
First, unless you go into psychiatry or radiology, you will be touching many people. This is most true in primary care. To fully assess your patients you can’t be squeamish about it. There are still bad sights and smells, but after a while these are not such a big deal. PAs don’t clean bedpans or give bed baths, but (depending on your specialty, of course) you will be working with people who are vomiting, emitting blood, pus, earwax, snot, blah blah blah. I just remind myself that that’s what any physician is exposed to as well, and that these things seen in a scientific light are important parts of the clinical process. But yes, at times I see things that I try to get out of my head as fast as I can. 🙂
Second, as a PA, you will need to explain what a PA is to many people. I was at a wedding last week and was chatting with a woman about my job and she asked me, “You’re a physician assistant, eh? Is that like almost a doctor?” I didn’t want to say yes, but it ended up being the quickest way to get the idea across. You should take from this that people know much more about what physicians do (PA is a pretty new field), so they tend to evaluate what you do in terms of how it compares to what a physician does. Thankfully, in most cases it’s a very favorable comparison. But there are definitely times when you instead will be asked “You’re a physician assistant, eh? Is that like a nurse?” or “Is that like a medical assistant?” And then you will need to explain more so that they get that it isn’t much like either of those things.
Just to round out my answer with a third item, I would say that one thing I dislike about being a physician assistant is that I often feel rushed. This is true of most medicine these days - PAs, MDs, and just about anyone in primary care or surgery. There are many patients, and to make enough money to pay you, your supervising doc, and the support staff of nurses, medical assistants, receptionists, bookkeepers, transcriptionists, records techs, etc., you will see many patients. I see anywhere between 25 and 40+ patients in a 10-hour day, which means that when the waiting room is full, I have to average no more than 15 minutes per patient. Some get less time, some more, depending on what they need, but I almost always wish I had a little more time with everybody.
I will say that I’ve always been happiest when busy - I feel useful and there is plenty of variety, so it works out for me, but there are definitely days when I miss being a psychotherapist (my old career) when I had 50 minutes for every client!
Thank you so much for replying. I will try to volunteer at a hospital or clinic(if possible ) so hopefully I’ll be exposed to the gross stuff. Lol. But I’ve decided to major in dietetics. I wanted to be a dietician before so I’m not forcing myself into the field. Hopefully it’s a good enough major to get into PA school.