Working with Death Wednesday: Doctor

Today I'm pleased to have a former classmate from Goucher College on the death writer blog.

Dr. Lainie Holman is a pediatric physiatrist in Cincinnati, Ohio. She is board certified in Pediatrics, Physical Medicine and Rehabilitation. She has two teenagers.

DW: Why did you want to become a doctor?
LH: At first, I was attracted to the science aspect, and the idea of being able to do something definitive to help someone. I still like those things, but after a while I began to realize that the part I dig most is the very intimate narrative that runs in the doctor-patient relationship. Everyone has a story, and everyone wants to tell it to someone who will listen. Especially to someone who is sworn to confidentiality.

DW: Have any of these stories shocked you?
LH:  In the beginning, but not anymore. It’s become more amusing than shocking. I had a kid once who was chewing on a string from his mattress quilting and managed to get it tied to his tongue. And the things they put in various orifices are hilarious. After a week or so, Rice Krispies in the ear are really gross. And there was once a kid who put a plastic Aquaman in his urethra.

But some of them remain very tragic. I had a patient recently who was born with essentially only a brainstem. His heart beats and he can breathe, but he doesn’t have any real cortical function. It’s something that might have been seen on ultrasound, except that his mother is 17 and didn’t know she was pregnant until she went into premature labor.

DW: Did you realize in the beginning of your professional journey that you would be dealing with death? I know this seems like a ridiculous question, but I have to ask it.
LH: Yes.

DW: Did you have personal experience with death before becoming a doctor?
LH: No.

DW: Do you remember your first patient who died?
LH: He was a previously healthy 3 year old who was hit by a car and who had a massive brain injury. The neurosurgeon was at his bedside to drill a small hole in his skull in order to place a monitoring device into his brain. I was a medical student, so it was my job to hold his head still for the drilling. When I put my hands around his ears, his hair fell over my hands and the texture was almost exactly that of my own three-year old son’s. He died later that night. I went with the attending physician to tell his parents. They were just completely destroyed. I will always remember his mother.

DW: How did you deal with that?
LH: Not very well. It bothered me for a long time. It actually bothers me a little now, honestly.

DW: Is there any sort of support for you or the people you work with after a particularly sad or challenging day?
LH: We have a busy chaplain service at my hospital, and mental health services available, but the usual method is just to talk about it with all the other people who experienced it along with you.

DW: What sort of misconceptions do you think the public has about your profession?
LH: I’d say almost all of the conceptions are mis-. That we are rich. That there is some kind of perfect treatment for complex disorders. That we can maintain some kind of patient, beneficent, attentive behavior at all times, even in the face of exhaustion, hunger, thirst, other people’s body fluids, hostile patients, and our own personal lives. That is just impossible.

DW: Do you find yourself keeping an emotional distance from your patients?
LH: Only the ones I don’t like. Another misconception. We don’t like all of you. It’s a relationship. Sometimes it’s really fun, and sometimes it’s not a good fit. But we have sworn to take care of the patients we don’t like just as well as the ones we’re attached to. Luckily, most of my patients are children, so I like them all. This would apply here to family members. Last week, I was giving a kid some injections and running late, so I hadn’t eaten lunch. The patient mentioned she was going out to a burger place after the procedure. I joked that I’d love a cheeseburger. When I returned to my office later, there was a cheeseburger on the desk.

I have another kid who walks, talks, plays T-ball and is pretty much fine. He has mild CP. His mother constantly wanted me to intervene and do medical things to him. I fired her.

DW: How about the patients you don’t like. Have you ever had to treat someone who had caused injury to someone else? Like maybe a drunk driver? If so, tell me about that.
LH: The one I remember most was a guy who was a passenger in a car on the highway. His girlfriend was driving. They were having an argument about something. He pulled out a gun and shot her in the head. She died, and lost control of the car and crashed into a bridge. He had a terrible brain injury, but we took care of him. He didn’t remember any of it.

DW: What is the most uncomfortable part of your job?
LH: Telling people something they don’t want to hear. Especially when they don’t believe me.

DW: Are we talking diagnosis?
LH: Diagnosis, but also treatment. On television, everything is fixable, and in real life, it just isn’t. Also, people want there to be a reason for everything, and sometimes it’s just bad luck. I had a kid just today with plain old community acquired pneumonia. His mother did everything she was supposed to, and he was appropriately treated, and his pediatrician did the right thing, and he still ended up with a pleural effusion, a couple days in the hospital and IV antibiotics for something that usually can be easily treated as an outpatient. No one did anything wrong. It’s just that sometimes pneumonia is funky. What people don’t appreciate is that pre-penicillin and immunizations children frequently died from pneumonia.

DW: As a doctor, do you have any advice for people regarding death?
LH: Get a detailed living will. Today. And a medical power of attorney to someone you trust to do what YOU want (not what they think is best).

DW: Is this fairly common? Family members trying to change a person’s end of life wishes? In your experience, does this happen with organ donation?
LH: No. Where things go awry is when someone designates a surrogate who either fundamentally disagrees with their wishes or who is too emotionally invested to make a hard decision. It isn’t that they try to change, but that they are in a very vulnerable place. It’s much better to spell out every single thing. My own living will stipulates that my POA has to consult with my roommate from medical school, who is a little more objective, is a physician, and with whom I have had hours of conversation about this stuff. Is that legally enforceable? No. But it gives her an out, and brings up a discussion that I want. You have to let the designate off the hook for their decision by being very clear.