Zebras and Death: my experiences this week in IM

While searching for an article to present at my next didactics day, I came across one titled “My Hidden VA List” by Dr. Dena Rifkin. I had to open it because I’m currently doing an internal medicine rotation at the Phoenix VA. In the article, the doctor writes about how the Phoenix VA national scandal does not line up with his personal experience as a VA physician. He says he keeps a hidden list of patients that he has had the pleasure of helping, the fortunate ones who walked out and the ones that weren’t so lucky. One quote in particular stood out to me. He states:

“My hidden list reminds me of some of my most difficult days as a doctor. It reminds me that shortness of breath can be a sign of acute myocardial infarction, that renal-cell cancer can recur years after the initial diagnosis, that men can get invasive breast cancer. Sometimes, I feel, I may sink under the weight of these names. As time passes, though, the weight of the list balances me. It prevents me from being too sure of anything, yet it also keeps me from hesitating to trust my instincts.”

This quote struck me for several reasons. We are taught as medical students to look for horses, not zebras- meaning that common things are common. If someone comes in with the signs and symptoms of pneumonia, it is most likely pneumonia and not some rare respiratory disease that we learned for our board exams. However, there is the rare occurrence of a “zebra,” a once-in-a-career disease that happens to show up on your doorstep. Or, rather, your ward. It is these experiences that shock, terrify, surprise, and delight physicians and med students alike. For me, it was meningitis from coccidiomycosis (Valley Fever). We have to keep our eyes open and not get anchored in the same 5-10 diagnoses we see day in and day out. We have to be prepared for zebras so we can catch them early and treat them and hopefully succeed at sending the patient home.

Another reason the quote stood out to me was because I saw my first death this week. A rapid response was called on the patient and my Attending and I happened to be getting coffee near the patient’s ward. We raced over to the patient’s room only to watch ACLS fail to revive the patient. Afterwards I didn’t know how to react or deal with the emotions I felt. To be honest, I came home and snapped at my hubby who finally asked what was wrong, and I broke down. Was it better for the patient to have not made it? Would they have had to live with the sequelae of oxygen deprivation if they had lived? What would his quality of life had been? What else could we have done? It just made me reflect on why I am so uncomfortable with death. In medical school, we never learn about death. Just that we should avoid it at all costs, including quality of life. We are there to SAVE the patient, are we not? Why would we ALLOW death to ‘win’ when that is our sole reason of existing, to prevent it? The Palliative Care team at the VA has repeatedly told us that death is as natural as birth. But for some reason, it frightens me. It makes me feel as if medicine failed. As if all of our extraordinary measures just weren’t enough.

A quote from “Scrubs” sums it up pretty nicely:
Dr. Cox says, “Pumpkin, that’s modern medicine. Advances that keep people alive that should have died a long time ago, back when they lost what made them people. Now your job is to stay sane enough so that when someone does come in that you actually can help, you’re not so brain dead that you can’t function.”

It is so sad but so true. Many times medicine is a necessary evil that prolongs life without prolonging any semblance of a QUALITY of life. We do help people- lots of people. Or I wouldn’t be doing this. But the bare naked truth of it all is that sometimes we do more harm than good. Sometimes we do all we can and people don’t survive. Sometimes they shouldn’t. I have to find a way to be ok with that and not see it as a failure. Because it isn’t. It’s as natural as any other life process and it can be a comfortable and painless process if we allow it.

My point in this post is simply to remind everyone to keep their eyes open. You never know what you’re going to see. You never know when you’ll see a zebra. But in the meantime, keep treating those horses. And if they don’t make it, try again. And remember, not everyone is intended to live longer. And that’s ok. It’s not a failure. It’s a natural part of life.


One thought on “Zebras and Death: my experiences this week in IM

  1. Death is a tough experience, mostly because everyone deals with it differently. My cousin is a clinical social worker who specializes in death and hospice. That’s opposite of what I want to do or even could do. Mostly because I’ve found it’s easier for me if someone is just gone, the long drawn out process is the difficult part. Hospice is hard. The thing that encourages me about you is your heart and your ability to feel these emotions in yourself. I think it gets scary sometimes when doctors (and even therapists) become numb to these things. There are ways to disconnect so people can stay clear-headed and problem-solve, but coping with grief and secondary trauma is a whole skill set on its own. The balance comes with practice and experience. Again, so proud of you for choosing this work. You are going to bring so much value to this field.

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