Funny, Smiling, and Dead in a Moment

She was funny. From the moment she arrived in the emergency room she kept the nurses and doctors entertained with quips and jokes. She was seriously ill but she was full of life. Within minutes she was gone.

She came into the emergency room complaining of fever, cough and fatigue. She had been feeling poorly for a few days, ill enough that she had gone to another emergency room a day before. They had not found anything so they sent her home. When she failed to improve she and her husband decided to try a different hospital. It was early evening when they came to hospital where I worked. I was the resident on call that night.

Her oxygen level was on the low side and she did not respond to the breathing treatments she received so even before he saw the x-ray the ER doctor decided she needed to stay the night in the hospital. He called me down to the ER to handle her admission. I spoke with the ER doctor briefly, reviewed her chart and went in to say “Hi.” She was smiling and upbeat as we talked. While we were talking I received word that the xray results were in. I left the room to review the films.

I was shocked at what I saw. Her entire left lung was filled with fluid. Instead of the dark open appearance of air the whole left side was entirely white. It was the worst case of pneumonia I had ever seen. We all realized that this delightful lady was much sicker than we had thought. She was deathly ill. I quickly arranged for a bed in the ICU. Within the hour she was in the unit and IV antibiotics and oxygen were flowing. She was still smiling.

Then her oxygen levels started to drop. Her breathing became rapid and for the first time her smile was replaced with a look of concern. We made the decision to intubate, to put a breathing tube down her throat and connect her to a ventilator to improve oxygen delivery. The attending asked me to perform the procedure. A sedative was administered and I moved to the head. I reassured her as I tilted her head back to allow for placement of the tube.

My face was 12 inches from hers. I held the laryngoscope in my left hand and the endotracheal tube in my right. Right at the moment when I moved to insert the laryngoscope into her mouth her eyes rolled back into her head. I heard the ominous tone of her heart monitor as it turned flatline. This wonderful 40 year-old woman had just died right in front of my eyes.

I continued on and inserted the tube as resuscitation efforts began. After a few hectic moments filled with the chest compressions, shocks and IV medications a pulse was restored. Her pulse came back, but she didn’t. The infection was overwhelming. It took a few days for cultures and tests to explain what had happened. She never had a chance.

She had been on prednisone, a powerful anti-inflammatory steroid, for quite some time to treat a form of arthritis. Unbeknownst to her the prednisone had weakened her resistance to stomach acid and an ulcer had formed, eroding deeply into the lining of her stomach. Eventually it eroded all the way through and acid and stomach contents had seeped into her chest cavity, carrying with it deadly bacteria. By the time she arrived at our hospital she was septic and bacterial toxins were taking over her body.

Within hours of the resuscitation in the ICU her organs began to shut down due to the septic shock. She was comatose. All of us on the medical team knew it was over. Her heart continued to beat and the machines continued to supply oxygen but there was no hope. She was gone.

The reality of her condition was impossible for her husband to accept. She had been so alive just days before and he could not comprehend how the woman he loved could be gone so fast. In his grief he was angry, demanding and defiant. He repeatedly insisted that something be done but there was nothing anyone could do. Many of us tried to talk to him but it took several for him to understand that she was gone, days spent alone at the bedside of a woman who was no longer there.

I have never forgotten either of them. They come to mind whenever I deal with the unexpected loss of a young patient. They remind me of the fragility of life and the inevitability of death. They remind me that every moment with the ones we love is precious, that every breath is sacred. They remind me to hug my wife, to tell her I love her every day, to thank God for her and to cherish her, for we all can be gone in a instant.

-          bart

When Sex is Dirty, We Lose

The world has changed. Things that were once completely unacceptable have become commonplace. Behavior once universally deemed shameful is now openly displayed. I have known this to be true for a while but there are still times when the magnitude of acceptable depravity catches me off guard.

I typically screen movies for content before buying a ticket as there are certain things I choose not to see. I subscribe to a website that describes potentially offensive content and use the descriptions as a guide, with a particular goal of avoiding sexual content. (It is my personal belief that in so doing I honor my wife.)

We recently saw a movie that contained sexual content for which I was not prepared. Their was a scene at the end of the movie that I missed in my pre-movie review. In the scene a young woman promises to allow herself to be used in a vulgar fashion by the protagonist. The act in question was repulsive to me and my wife and, prior to the movie, I thought it was repulsive to others as well.

The scene shattered my illusion. As we walked out of the movie disgusted we both expressed amazement that the act in question was not only portrayed as possible, but desirable. We realized that the film makers must have believed that the audience would agree with their portrayal. How could this be?

I think what we saw was the natural cultural outcome of a lack of moral clarity. Right and wrong are no longer clearly and consistently defined in our culture. In fact, the opposite is now true. We live in a world that values pushing the envelope, that believes moral restraint is something to be rejected instead of embraced. What we observed is the natural consequence of the abandonment of moral standards. If there is no good to be pursued there is no evil to be avoided and the perverse becomes normal.

What is most tragic is what people miss when they reduce sexuality to nothing more than a service one person performs to or for someone else. Love is missed. Intimacy is lost. Marriage loses meaning and loses relevance and stability. 

We went home that night glad that we are different. For thirty-three years we have pursued love, grace, and honor in our relationship with each other. We view intimacy as a sacred gift given to us by our Creator and we have nurtured and protected that gift. The result is a bond that is beautiful and unbreakable, a bond that will endure. A bond that too many others seem to have lost.

- Bart

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Poisoned by a Doctor! (And other Accusations)

“You doctors just want to give me poison and I am not going to take it!” I have been accused of many things in my 20 years of practice but intentional poisoning was something new and the patient's words surprisingly harsh. He was angry from the moment I walked into the room. He was first offended when I questioned his reasons for not taking the medications his cardiologist had prescribed. He had experienced some slight swelling of his legs, decided that this side effect was too severe and made the decision on his own that the medication was unsafe. He was convinced that the doctor had put his health in danger and that I wanted to do the same.

When I explained that this was a relatively common side effect with this medication he became angry. “Why would you prescribe a medication when you know there are side effects?” He was nearly shouting and his faith was contorted in anger. He was MAD!

“Because it is an effective drug and the side effects only happen ten percent of the time!” Was my reply.

He would have none of it. It was his opinion that no doctor should ever prescribe any medication if there were any side effects. I tried to explain to him the nature of side effects and how they were outweighed by the benefits of treatment. I spent the next 20 minutes trying to explain to him the nature of heart failure and why medicines were crucial for his health. I explained how the medications worked and why the side effects were reversible or manageable. He argued with me every assertion I made. He told me that doctors were dishonest people who cared more about money than they did people, unscrupulous individuals who would just as soon poison someone as treat them.

I finally gave up. As calmly as I could I told him that if he was going to refuse care for his heart failure that I would not be his doctor. If he didn't trust me it would be impossible for our relationship to continue. I explained that my preference would be for him to remain a patient and be healthy but that remaining a patient and being healthy would mean following my instructions. He continued to argue with me so I opened the exam room door and gestured for him to leave. “You will need to find another doctor,” I told him, and sent him on his way.

After he left I composed a letter summing up what had happened (detailed documentation is required when a patient is dismissed) and put it in the mail. I reviewed our conversation and concluded  by saying,

“You made it clear that you do not trust doctors, myself included. The physician/patient relationship has trust as its foundation. Your good health and medical treatment is dependent on you following expert medical advice. Our lengthy conversation today proved to me that you are unwilling to do this.

If you wish to remain a patient in my practice, you will need to accept and follow my recommendations, and schedule appropriate follow up visits. If you are willing to follow my recommendations and respect my judgment and opinions, please schedule a visit to move forward with your care.

If you plan on continuing to argue with my recommendations and refuse to comply with treatment plans, I must insist that you seek care elsewhere.”

I had my staff send the letter via certified mail, convinced that I would never see him again. Which is why I was so taken aback when I saw his name on the schedule 5 weeks later. I entered the room cautiously, prepared for another conflict.

It never came. He was incredibly apologetic from the outset. I asked him what changed his mind. He told me it was the letter! He realized that I was serious about his health and decided right then that he didn’t want to see anyone else. 

His dramatic change of heart was something else I had not seen in 20 years of practice. I was truly impressed with his humility and told him so. We agreed on a new medication plan for his heart and blood pressure and arranged a follow up visit. It was a very pleasant encounter.

It was also educational. He taught me that people can change, even those who seem intractable and unreasonable. He reminded me of the power of forgiveness and the beauty of a fresh start. I am actually looking forward to our next visit.

- Bart 

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Growing in Love after 77 Years

They have been married for 77 years. Les is 97 and Betty is 93. Age has affected them physically, mobility is difficult and they require assistance in caring for themselves and moving around. Even with their motorized scooters getting to the dining room at the assisted living facility has become difficult, so staff brings their meals to them in their small apartment. There seems to always be a styrofoam container of the previous meal present when I come to visit.

Routine is important to people in their nineties and they are no exception. They sit in their same recliners for most of every day, watch the same TV shows (It is ALWAYS on Fox News), and he tells the same jokes over and over again.

There is something else about them that never changes. They love each other. Even more, they like each other. They enjoy one another’s company. A few months ago he was hospitalized twice in a matter of days with pneumonia. There was a concern that he was losing the ability to protect his airway and might not be well enough to remain in their assisted living facility. He was told he needed to go to a nursing home so he could be kept out of the hospital. I told him he could stay in assisted living with his wife if but that if he got sick again he would need to go on hospice or be transferred to a nursing home. Since a nursing home would mean separation from his wife the decision was a simple one for him. He would rather live a few months or less with his wife than live a few years more without her. “I want to stay with Betty,” was his firm answer.

Their story stands in stark contrast to many of the stories I hear in my office. Unhappy marriages are so common they appear to be the norm. Patients who speak fondly of their spouses, who talk about marriage as if it is a gift, stand out as exceptions. When patients hear me talk about being happily married for over 32 years they are often surprised. Long, happy marriages are not something they often see.

I often wonder why this is. 

As with so many things in life I think success in marriage is a matter of choice. Successful marriages occur when a man and woman make a conscious decision to build a quality marriage. Happy couples understand the costs associated with this commitment. Sacrifice and self denial are required daily. Faults need to be overlooked or graciously accepted and effort needs to be made to intentionally focus on the good things in a spouse’s character and personality. Over time, things that once required effort become second nature, and love grows. When we focus on the good in our spouse they grow in value and we enjoy them more. 

Lisa and I are 44 years behind the example set by Les and Betty Miller, my grandparents, but we are on our way. We have experienced firsthand the joy that marriage to your best friend brings, the work required to keep a marriage strong and the contentment that comes from not wanting to be with anyone else. Life with your one love is a very wonderful thing.

- Bart

If you are in a marriage that is unhappy, get help. Your marriage is worth fighting for. If you are in a marriage that is “just okay” get help. Fight to improve it. You will never regret making your relationship with your spouse your top earthly priority! Remember you can subscribe to the blog by clicking the button on the page or follow me on twitter @bartbarrettmd.

A Good Man Dies. Or Does He?

Allan Meyer died last week. Although he was in his 80’s it was unexpected. He was a friend to my wife and her family for over fifty years as well as a consistent source of encouragement to me. He was a natural encourager. He seemed to seek us out every Sunday, as if had a special radar he used to seek us out so he could greet us with a smile, a kind word and a silly joke. He was a lover of people who frequently visited friends and church members who were hospitalized. He was a good man. Today is his memorial service. I expect it to be a long one. There is a lot to say about Allan and a lot of people who will want to say it. 

It seems that this is how it works, that the true value of a life comes into clearer focus when it ends. Death is the time when our true worth and accomplishments are understood. Death is the great commonality, an event shared by all regardless of culture, ethnicity, social status or religious faith. It can be delayed but it can never be avoided. Everyone dies. When they do, people reflect on who they were and what they did.

Death also brings with it a question. What comes next? The answer to this question defines all human existence and brings the standard by which all lives are measured. Answers vary, yet all of the possible answers have profound ramifications for how people think and live.

The secular answer to the question of what comes next is simple. Nothing comes next. The  final heartbeat and last breath represent the moment when the person completely and totally ceases to be. Nothing remains of their personality, their emotions, feelings or memories. They are just gone. Death is the absolute end.

People of faith answer the death question differently. For them life follows life. The body ceases to function but the essence of the person, the personality and thoughts, the soul and spirit, continue on. 

Believing that something comes next changes everything. If there is a next life, particularly if it is an enduring life, then earthly actions must be measured not solely on their immediate impact but according to their impact on the life to come. Earthly wealth and accomplishments decrease in importance. Faith assumes the preeminent position and character qualities such as love and faithfulness and a person’s relationship with the Divine outweigh those things which can be seen by the eye. 

While worldly achievements are in large measure dependent on when, where and to whom a person is born  the things that matter for eternity are available to all. Faith, hope and love are gifts that can be received and given by the poorest of the poor.

A person’s true answer to the what “what next” question can be determined from a distance. Those who pursue pleasure and happiness with vigor, who work hard build a name or legacy for themselves, and strive for earthly success are living as if this life is all there is, as if they embrace the secular view. Further evidence of a temporal mindset is seen in rejection of moral absolutes. 

People who hold onto earthly goods more loosely, who are more willing to forego wealth and security in this life and more willing to give their lives for a cause are living as if there is an eternity.

What we believe about death defines our entire existence.

• From what I observed, Allan was a man who believed in eternity. It is why he lived as he did and loved as he did. I look forward to seeing him again.

- Bart

Prayers for Allan's family will be appreciated. He is at peace, it is those who remain who are suffering.