When you're done getting dressed, take the rooster to the front desk

Sue Lowden is a Republican running to capture Sen. Harry Reid's seat in Nevada. Recently she suggested that we should go back to the days when people paid their doctors directly, whether in money, or you know, if they didn't have the money right then, then maybe, barter, with, you know, like, chickens and stuff. That back-to-the-old-days nonsense is so phenomenally stupid, it nearly begged for someone to set up this site:

Prices of medical procedures in number of chickens.

Make sure to read the fine print to properly adhere to the plan's rules.

For big procedures, the site suggests possibly converting to cows.

On the other hand, teaching hospitals might consider accepting chicks in order to subsidize medical education--and to pay residents with. Residents, being mere doctors-in-training, should be paid in chicks rather than in chickens. This will also allow them to invest in their future. Once the chicks grow up, they can be used to pay off student loans.



The Democratic Senatorial Campaign Committee has a different plan available.

Unbelievably, after taking a week of jokes (Jay Leno: "But what if your doctor isn't Amish?"), she continued to promote this idea, in the tone of making a helpful suggestion for the folks at home.

How to declare people dead.

First step:

Examine the person who may be dead.

Their pupils should be fixed and dilated--that is, showing no responsiveness to light and remaining fully open. They should not have a blink reflex when something brushes against the cornea of the eye. They should have no heart sounds for one minute of listening. They should have no breath sounds, and no other evidence of breathing. They should be unresponsive to deep painful stimuli (e.g., pushing down sharply and rubbing the sternum--the middle of the chest). Especially if they have been brought from somewhere else rather than dying in the hospital, they are "not dead until they are warm and dead", because hypothermia can mimic death by slowing down and dampening down all bodily functions.


Next:

Write a note in the chart. Like all other notes in the chart, sign it with your name followed by "MD".

Declare the person to be dead by filling out a form for the hospital admitting office. Call the office and let them know the patient is dead. If need be, they can tell you your medical license number which you are supposed to put on the form; you've only recently become a doctor, and you can be forgiven for forgetting it.

If the death meets any of the criteria listed on the admitting office's form, call the medical examiner's office, who has the right to require an autopsy. You were told in intern orientation to make sure to get the name of which doctor at the medical examiner's office refused the autopsy, or at least which staff person you talked to. You might forget this part. Thankfully you can call back and the ME's office can remind you.

You're required to ask the family if they want the autopsy. The pathology residents require a certain number to graduate from their program, and they've asked you to please try to get autopsies. In theory, autopsies improve healthcare by showing what we might have done wrong, and showing whether our ideas about a person's medical problems were correct. Still, your own inner compass demands that you be gentle about this, and fortunately the vulture-like quality that might surround the request has been taken out of your hands, so that if the autopsy is obviously a dumb idea, you might simply say, "We are required to tell the next-of-kin for everyone who dies that you have a right to an autopsy, at no cost to you."

If the family wants the autopsy there is a consent form. Walk them through it. Once they've consented, sign your name, with "MD" after it.

Based on your earlier phone call, the hospital admitting office fills out the death certificate and pages you when it's time to come down to sign it. Bring the rest of the paperwork also. If you get caught up in something and lose track of time, they'll page you again.

Fortunately, they're there all night. At 4:30 am, as the morning lab results are just starting to trickle in on your MICU patients; as the x-ray tech wheeling around the portable x-ray machine is calling out "X-ray!" as he presses the button to take the morning chest x-ray from outside your patient's room; as he goes and pulls the x-ray plate out from under your sedated and ventilated patient's back, and moves to the next room to repeat the process; and before the sun begins to illuminate the glassed-in walkway between one part of the hospital and another, you can take the elevator down to the little no-windows office with cubicles and dull flourescent lights.

The admitting office workers are sitting in one of the back cubicles with stacks of paper around them. At that time of night one of the admitting office staff members might be doing a crossword puzzle when you arrive. But they know right where the death certificate is; your arrival is a key item on their to-do list, because it has to be done before they can release the body to the funeral home. Don't fill out any of the information on the form--they do that, and anyway, you'll just mess it up. If you start filling out the address and time and date information, they'll have to start a new death certificate. So just sign it with your name, followed by "MD".

Then, when you have a moment:

Recognize that the structure of modern society is to make life and death themselves medical and then legal matters, and to subject the most basic elements of our existence to professional authority. The birth certificate and the death certificate are signed by doctors, and then registered by the civil authorities. The "MD" proves the certificate's legitimacy as a reflection of an actual biological fact.

The birth certificate is not simply an extra voter created by a political machine, but an actual person with a beating heart. The death certificate is not a way for someone to escape their creditors or start anew in another city or make an insurance claim; it reflects one body's stopped heart. The doctor declares a biological process to have definitely begun, or to have irrevocably finished; the declaration of biology is necessary for the legal and political legitimacy of the state. A modern state must be able to keep track of who is born and who dies. This is an important distinction between wealthy nations and impoverished failing ones.

A person who was born without a birth certificate is a person without a legal identity. And a person who is dead but does not have a death certificate is a body in limbo, kept in a hospital morgue until the form is signed with "MD". Without this the body can not be buried; our funeral rituals of helping the person to pass from this life into whatever follows can not take place until a doctor signs the form that verifies that the person has indeed left this life.

Taking the elevator, back up to the ICU, you might think how strange it is to hold a doctor's power. The fact that declaring death requires your presence, your examination of the body, your ritualized declaration, your signature on the forms, are all part of how we wrap death in our own forms of modern technical expert solemnity. You understand why it's a good idea to be sure that someone is dead before you declare them dead, and why a doctor is called on to make sure. Still, to find yourself called to verify the death of a human body that everyone knows is dead is a strange task. You understood that the power of prescription, and the knowledge you hold, and the social role you play, all give you power in the hospital and in the world. But you might now realize for the first time that you are also an official of biological fact, called on by your state to be the neutral observer, to translate the natural world into civil forms and statistics.



As I was taking pre-med classes, one of my dearest friends was going to get married to his then-girlfriend, who had also become a dear friend. They asked me to officiate at their wedding. Of course I was deeply honored, and went immediately to the internet to get myself ordained as a minister--because for the state, sealing the bonds of love requires other distinct forms of authority.

But I also asked them, "Why did you think of me?" Among the things they said was, "Well, you're, like, a doctor." And I said, "No I'm not!" (I still hadn't got through organic chemistry. The outcome was still deeply uncertain.) And they said, "Well, almost." And I said, "Anyway, what does that have to do with anything?"

They tried to explain, and I think what they meant was that by virtue of simply aiming to become a doctor, I had acquired a kind of gravity, a seriousness that was different than their other friends. Or perhaps even more likely, by announcing my intent of becoming a doctor, I had begun to publicly acknowledge the part of myself that wanted to play that kind of role within my community and my society.

That was a long time ago. The daughter they had well after their wedding now has opinions about tacos, burritos, and their relative merits. After all that time, I finally have actually become a doctor, and I have taken on that ceremonial gravity in other ways.

"...I examined him and found his pupils to be fixed and dilated; he had no corneal reflex; he had no heart sounds for one minute; he had no breath sounds, no air movement apparent at his mouth, and no chest excursions; he did not respond to sternal rub or firm pinching. Time of death: 4:45 pm.

Joe Wright, MD. Pager #81987."




*

Fear really is the mindkiller

ACLS training today. That's Advanced Cardiac Life Support--it's where you learn how to shout "Clear!" and deliver a shock; or, "One milligram of epinephrine!" Just like TV. (Except, you shouldn't shout.)

I passed the written part of the exam with 100% of the questions correct (not a super hard test, and my result was shared by many present, but still, it was satisfying). Then we went downstairs to do what the American Heart Association calls "Megacodes" which inspired some of us earlier in the day to keep saying "Megacode!" at random times during breaks. (Well, mainly me, actually. But I'm sure that others wanted to.) The megacode involved standing with a mannequin and a bag-mask and a defibrillator; while an instructor ran us through a basic simulation of cardiac or respiratory emergencies.

I was the first to volunteer to be a team leader, and it was brutal: I couldn't remember whether the pathway we were on led to adenosine or atropine. The sonic similarities of the two drug names caused me to merge these two drugs, which are not at all used for the same things. In the larger sense, I did the right thing in that I knew I was in doubt and asked my team members--who said, no, it's not adenosine. And though I was then able to say, "OK, right, atropine 0.5 mg IV"--still, I was miserable at the end.

The schedule isn't actually out yet, but I have reason to think I'll be starting in the ICU next Saturday. If it's true, that means I'll be on the code team starting within the first three days of internship. As long as my resident answers the code page as fast as I do, I'll be fine: I'll take orders, bag-mask, do compressions. We'll sprint down staircases in our scrubs, and as long as my resident is running right there beside me, I feel more or less ready. Excited, even.

But if the resident is in the bathroom? Doesn't hear the code page? Is dealing with some other emergency? It's unlikely, but I fear being, for even a minute or two, the only MD in the room. Because we are the ones with prescribing capability, we end up being the people who call for drugs. And therefore, the MDs generally become the team leaders. Even, it seems, when my ACLS instructors who work as respiratory therapists or nurses are also on the team. (I wanted to ask, "Seriously, you started working as a respiratory therapist when I was two years old, and I'm one of the oldest interns in the place, and I'm the one who's supposed to run the code?" But it didn't seem like the right time or place for that conversation; I'll save it for a night in the ICU when there is time and quiet.) Thankfully, asking for help is encouraged. As long as there are other people there--and if the code cart and the drugs that freak me out are also there, that means that someone else will also be there--I will be OK.

Still, mixing up the drugs when I was suddenly on the spot and feeling nervous was scary. That in turn made me upset and worried enough that I started having a hard time concentrating on the next cases and on what the instructor was telling us after I was done. I actually said to myself: "I will not fear. Fear is the mindkiller" in my internal Kyle Maclachlan voiceover voice, and with that, I was able to force myself back to the present, to the work in front of me.

Also I went around and talked to a couple of people to see if I could find a way to do some simulator sessions before internship starts. I want to pound on some mannequins, and see if that helps.

How I changed, part 1: life and death

"Any animal’s minute-by-minute life is a constant process—or actually, a system of many interlocked processes. All of us animals are constantly kept alive by our systems of life." Video: the Hemodynamic Cat takes a nap.

“This process must have changed you,” my friend R said, as we were talking about my upcoming graduation from medical school. “But how did it change you?”

I’ve been thinking about that ever since, and I’ll be thinking about it more—this surely won’t be the last that I write about it.

* * *

Life and death changed around me even in pre-medical biology classes, but much more acutely as a medical student. Walking along a crowded beach, or out in nature, or even sometimes in the city, I much more frequently and knowledgeably remind myself of the physiology of the life around me. There are the big bipedal apes (you know, us); the birds; the dogs; the fish in the sea. When I see a dog running down the beach, or children splashing in the waves, or a row of birds flying in formation, I am much more likely now to remember how they are able to do these things. Their hearts are beating, their lungs are taking in oxygen, the mitochondria of their cells are using the oxygen for biochemical reactions which allow them to store energy, and the cells of the brain are using that energy to direct the activity of the rest of the body.

Any animal’s minute-by-minute life is a constant process—or actually, a system of many interlocked processes. All of us animals are constantly kept alive by our systems of life. Those systems are so complex that even after a lifetime of me learning about the biology of people alone (never mind birds, or dogs, or fish), I will die having learned only about a fraction of the cells and molecules and organs that will have kept me alive until that moment.

And if any of it stopped for any of the animals around me, the whole scene would change. A bird would fall into the water. A man would fall down on the beach. A dog would stop moving. The change from my previous life is that I more frequently remember that these underlying processes must constantly be working to allow the life around me to keep living. I more reliably remember some basic information about how these processes work. And so I more often appreciate that their workings all around me—the panting of the dog, the shouting of the children, the bird using its muscles to flap its wings—are each made possible by still more mechanisms. I more frequently notice and love the baroque and beautiful details of life.

* * *

I came to understand emotionally—and not just intellectually—that life is not the default. In fact, life is an improbable and incredible struggle made possible only by a constant cooperative struggle of cells working against the processes of entropy. Death no longer surprises me, though it still can upset me.

I first began to understand my own mortality at around the time a lot of people do, in my early twenties. But my understanding began in the midst of the HIV epidemic. Before medical school, I devoted a great deal of my work life and much of my volunteer civic energy to the cause of preventing new HIV infections. And partly because my consciousness of death came from HIV in the early 1990s, I was always conscious of the possibility of death, but I was always engaged in the effort to prevent it.

A few years after I started doing HIV prevention work, a high school friend of mine was diagnosed with metastatic cancer. I was not much involved in her care, and although we stayed friendly throughout, her social world contracted to a small circle in which I was not usually included. The one thing that my partner of the time and I were able to do to help was to find her and her boyfriend an apartment in San Francisco, which at the time was no small feat. The apartment was immediately below us, so although I did not see her socially very often, I saw her through windows or during comings and goings, and saw her getting more and more skinny and weak. I saw her boyfriend going through many stages of worry and grief. I knew when she died.

Though I knew intellectually that it shouldn’t, emotionally her diagnosis and death surprised me. My friend seemed like a buckle-the-seatbelts, wear-your-condoms sort of person; she won lots of the good student awards in high school. My surprise and shock about her death helped me see that my public health work had an irrational emotional abscess festering within it: the hope that somehow everyone could be saved from death if we all just behaved ourselves. Looking back, I think that her death was one part of my trajectory towards medicine. It helped me towards the very beginning of realizing emotionally and viscerally that death and suffering is a part of life--and not just the product of a particular epidemic that had to be stopped.

When I got to medical school, death gradually became much more a part of my regular experience. Two different anatomy classes (the required one and an optional one) meant that I dissected two different bodies. This required a very lengthy and detailed involvement with the bodies. And that meant a close-up constant literal immersion in the fact of death.

Then there were my patients, many of whom were dying, facing life-threatening diagnoses, or fearing the possibility of death; and some of whom died. I actually gravitated towards some of this in medical school. I took more oncology-related rotations than most people do, and I did an ICU rotation. Before death, there were worries; struggles with families and within families; various forms of physical suffering, and even more forms of emotional suffering. Death started to seem like the simple part. Living near death is much more difficult and complicated.

From being immersed in the bodies of my two anatomical donors, and then also from physical exams, Pap smears, stitching up wounds and draining abscesses, and standing next to surgeons in the OR trying to make myself useful, I got the immediate and now deeply-remembered sense of the physicality of our bodies. Before medical school, I was moved and fascinated by the fact that we were only frail physical bodies. I once wrote a kind of prose poem about it, which I must have in an old notebook somewhere. But I did not regularly make the emotional leap from my intellectual or poetic understanding of this frailty. That emotional leap required learning biology. It required knowing in detail the ways in which we are physical beings. Knowing these details convinced not only my intellect but my emotions that our physical selves must eventually cease to exist.

I am not a religious person: I believe that who we are is contained by our physical selves. Biology is the beginning and end of life, and it is life itself. We live because our cells work. We die because of the built-in limits of our cells and the systems they make. Even those limits are part of our biology.

It shouldn’t be a surprise to me that going to medical school helped me understand life and death in a different way. But I think I hoped when I started that the understanding would come as a mystical or philosophical insight, or some spiritual catharsis on a call night. That’s not what happened. Instead, I learned biology, and learned more biology, and then I started seeing life as biology, and biology as life.

How we feel about all of this, and what we say to each other about it, is important; but how we feel and what we say is also part of the beautiful biology of long-lived social animals. We are bipedal apes; we use tools and language; our hearts beat. Like pelicans and elephants, we are born, we live together, and then we die.

Photo: based on their behaviors, it seems reasonable to believe that elephants mourn the dead.