What's up, Hubski?

As I've disclosed in other comments I've made here, I'm in training to be a physician. Something that has been on my mind of late - both at a personal level as it applies to my own life but also within the context of medicine as an institution and what we actually do for patients - has been mortality.

I'm the kind of person that has been acutely aware of my own mortality since I was pretty young; I remember having the thought that I, too, would die at some point as I was going to sleep one night when I was 7 or 8. The thought terrified me - and, at times, it continues to do so. That my existence is finite and that death is permanent, eternal, and irreversible was and is disconcerting. I would like to think that I've matured since initially having this epitome, but if I had to answer the question, "are you afraid to die?," I think my answer would still be yes.

This sort of philosophical backdrop, in retrospect, makes me wonder why the hell I had any desire to become a physician - a job which inevitably involves intimate involvement with death. Though I'm a psychiatrist - a decision driven, in part, by my lack of desire to deal with people that are acutely ill in the "probably going to die pretty soon" sense - I will, of course, still deal with death. Mental illness is in many cases a terminal illness. Death by suicide is the ultimate complication, and in with the more severe illnesses (e.g., bipolar disorder and schizophrenia), suicide rates are disappointingly high despite treatment (anywhere from 10-25% depending upon the data you use). I have been fortunate enough to not have a patient under my care die yet, but I'm not foolish enough to believe that I can get through my career on a perfect streak. I couldn't imagine be a trauma surgeon, an intensivist (a physician, typically a sub-specialized anesthesiologist or internist, who works in the ICU setting), or any other physician that works with the acutely dying or near-dying on a daily basis. Naively, I still cling to the notion that my job is centered around not just keeping people alive, but enabling them to live a good, healthy, and fulfilling life.

This notion was challenged today, and it once again made me acutely aware of my own mortality. One of the long-honored traditions of medicine is the "morbidity and mortality" conference. These conferences typically involve the members of a department (e.g., cardiothoracic surgery) and involve discussion of patients in which there were unexpected complications (morbidity) or deaths (mortality). The impetus behind these conferences is to learn from them: in them, everything goes and candor is the rule. The point is not to place blame but, instead, to identify where shortfalls occurred if they did occur and how we can correct our systems and processes to prevent those shortfalls from happening again.

Today's case was a young man, an older teenager, who presented to the ER for sudden-onset blindness. An opthalmology consult was ordered, and examination of the retina revealed an occlusion of a branch of the retinal artery (the primary blood vessel responsible for providing blood flow to the retina, which itself is responsible for our ability to see). Initial workup involving a bunch of labs revealed a much more serious picture than expected - multiple findings suggesting systemic inflammation and widespread organ dysfunction though not outright failure - and he was quickly admitted for further care. He had no history of health problems and was otherwise healthy - an "upright citizen" (code for no drug use, risky behaviors, or other history of social problems that might otherwise impact health), as one physician at the conference described him. It was eventually discovered that he had bacterial endocarditis, or an infection of the valves of the heart. In particularly bad infections, this can lead to complete heart failure and death as these valves are critical to ensuring that the heart pumps effectively. A cardiac surgeon was consulted that evening - in these cases, valves are typically replaced and the patient treated with antibiotics - who ultimately decided to wait to operate in the morning given that he clinically looked well and he would have the advantage of a full set of staff available to help him in the case. A few hours later, it was noticed that he was looking acutely worse and had difficulty breathing, and shortly thereafter he went into cardiac arrest. A code was called, and he was successfully resuscitated multiple times but kept arresting. He ultimately arrested and was unable to be resuscitated and was dead less than 24 hours after arriving to the hospital. The case was especially heartbreaking because of his age and otherwise excellent health; in short, he simply wasn't the kind of guy who we expect to die suddenly in the hospital.

An autopsy revealed that he had an abscess (essentially a walled-off infection) involving his aortic valve and extending into his heart; it's believed that the infection expanded so far as to interrupt the heart's electrical conduction system, causing it to arrest. When he was still living, blood cultures to identify the presumed infection were obtained but had not grown out bacteria yet (it takes time for those buggers to reproduce enough for us to identify them). Those cultures as well as a culture of the abscess following his death revealed an infection due to a bacterium that commonly causes cavities. There's no way to know for sure what happened, but it's very likely those bacteria were dislodged during recent dental work, built up an infection in the heart, and - since he was young and otherwise healthy - grew without many symptoms until his body was unable to compensate any further.

This story was a stark reminder of the incredible toughness - illustrated by his ability to live with this infection for what was likely weeks or months - and its fragility. It reminded me of the incredible suddenness with which life may end. Do you think this kid had any understanding or expectation that he would be dead the week before he arrived to us? And it reignited by hypochondriasis and neurosis when it comes to how I interpret my own maladies. A random episode of numbness becomes, to me, a sign of multiple sclerosis or Lou Gherig's disease; headaches make me fearful of a brain tumor; some recent episodes of anxiety presenting largely with cardiac symptoms raised the possibility that I might have some undiagnosed heart abnormality that would result in my untimely death (comfortingly, "sudden cardiac death" is an actual diagnosis).

Most importantly, I was reminded of medicine's potency at pushing back death but also of its inability to prevent it. I struggle with the dichotomy of being concerned about my health - of being aggressive when it comes to seeing a physician and living as healthy a lifestyle as possible - with the reality that I will still die regardless of what I do and attempting to forgo the anxiety associated with self-diagnosis and constantly wondering, "is this the symptom that does me in?" In medical school, I spent a year learning about the elegance and beauty of the human machine, the next year learning every possible way it could (and does) go wrong and result in our ultimate demise, and the next two seeing those stories play out in real people. Even after those experiences, I'm still left with an uncertainty about it all: whether this profession is as noble as I once thought it was; whether we really do all that much good; and whether worrying about my own death is a relevant concern I should dedicate bandwidth to or not (and my incredible failure to control my visceral reactions to the realization that I must and will die).

I use that story as an introduction to ask: how do you frame your own mortality, Hubski? If you've managed to become comfortable with your own mortality, what insight or experience made that possible for you? If not, what emotions does the thought of your mortality bring to you, and how do you deal with them in productive (or unproductive) ways?