I was recently taught about the very basics of bedside echo. Prior to even playing around with the ultrasound machine, I was taught about the different bedside echo views. Parasternal short axis, parasternal long axis, apical 4 chamber, apical 5 chamber, subcostal. The idea is that each view will allow a different plane when visualising the heart. This concept can be likened to how being in the same room but looking out a different window will show a slightly different view of the outside world. An outside world which seems pretty far off in the vitamin D-deficient land of being cooped up in the hospital walls. But nonetheless, your ultrasound view will depend on where you decide to place the probe and what you place emphasis on. Subsequently, what we place the greatest emphasis on becomes what matters and what we focus on in that particular view. I thought about this when I met Eugene.
Eugene* was an elderly gentleman admitted to the ICU for respiratory support and ongoing management of an infection in his bloodstream. Now you might think was a fairly common presentation to the ICU, and you’d be right. But Eugene was also a doctor. He was retired and had been for many years now. On the morning ward round of his admission, we explained to Eugene the results of his most recent investigations and the suggested management plan. But it was an explanation in the medical parlance that medical people seem to like talking to each other in using big words you spend all those years in medical school learning (which I probably still seldom understand). It felt like a recognition of kin.
The next day on the morning ward round, I was asked to examine Eugene. He looked different to yesterday. He looked fragile. He was wrapped up in a warm gray blanket from home that looked like a warm hug and hot chocolate - vastly different to the cold-feeling white hospital blankets. I washed my hands (don’t worry – we do that these days) and approached him and softly asked how he was feeling that morning. He said he felt tired. It was a strange instinct that kicked in. Being extremely inexperienced, I’m still learning a lot about what these different instincts mean and how to hone them skilfully. But I later learned that this instinct was about someone who was going to die soon.
Surprisingly, doctors die too. A seminal article published in 2011 voiced an opinion that doctors die differently to their patients. It articulated the idea that having been on the administrating side of putting down breathing tubes, performing invasive procedures and surgeries on patients led doctors to accept end-of-life care that focussed on quality rather than quantity of measures. What a noble ideal to entertain that I may not go kicking and screaming into the good night when my time comes. Unfortunately, it doesn’t seem to be in my nature to back down without a fight. Interestingly, a study performed in 2019 compared the end-of-life care received by physicians compared to non-physicians in Canada. This cohort study compared 2507 physicians and 7513 non-physicians with the primary outcome being location of death and secondary outcomes including measures of health care used in the last 6 months of life. The study found that there was no overall difference between physicians and non-physicians.
In fact, the group found that physicians were more likely to die in an ICU. I think this is comforting because perhaps doctors can be just as vulnerable as their patients. We all want to be cared for deeply, throughout life and especially at the end of life. So it approached home time for me but Eugene’s family had yet to arrive. I decided to stay past my designated home time. I stayed because I wanted to make sure that Eugene didn’t die alone. In his last moments, what I wished for him was that he could be wrapped up in the long love he had shared with his wife and have his family around him. Upon reflection, I think that perhaps when someone approaches the end of their life it starts to become more about the living than about the one who is passing on.
So you thought this drivel would be about bedside echo. Let me reassure you that I will not be the one educating you on that particular topic when I can barely steady the probe in the goop long enough to successfully cannulate someone. But think about the different views of the heart. Think about what you can see from a different perspective, whether its thinking about dying as a doctor or dying as a patient. Most of us don’t think about how much choice we really can have at the end of life. Let’s lessen the chasm of perspective between those who contend with life’s fragility and those who don’t. In the end its all the same – its more about what we decide to place emphasis on that informs what view we see from the window. Luckily, Canberra offers some pretty spectacular views.
*All patient names have been changed and details omitted/changed for the sake of confidentiality
Proper readings instead of the drivel you just read:
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