July 30th, 2013

There is a patient on my team’s service who tried to kill himself with alcohol and drugs.  He is now sitting in the Intensive Care Unit on sedation with a tube down his throat bringing oxygen to his lungs and brain. I measure his reflexes day-by-day and his prognosis is looking more grim with each passing day.  The longer he is here, the more problems arise and there are infections and hematomas to add to the severity of his situation.

At first it was hard for me to wrap my mind around this case.  If the man wanted to die, why are we working so hard to keep him alive?  It is apparent that he is a chore for all involved with his care.   It’s difficult to take a person from the brink of death and find a way to bring them back to life, and even if we are successful, will he even be able to live an independent and meaningful life? I can't help but be sad for him, as the condition is self-inflicted, but my sympathy is hard-bought (more so than I care to admit).

Today on rounds I was bored; he was not my patient.  I was also hungry and we had not been given the chance to sit since 7am and it was now around 1pm (I’m still getting my legs trained for the long days on rounds.  Some days they last 40 minutes, but most days they last upwards to 5 hours! My greatest priority now is getting comfortable shoes...) I was ready for it all to be over, and another comatose patient was not going to help me pass my shelf exam. 

While discussing this patient, the resident said it best: “Even if he is a suicidal, alcohol-abusing patient with a multitude of problems, we, as his doctors, owe him the best medical care we can give.”  It might be cliché and pithy, but today it was the message I needed to hear.  At the moment I don’t get to choose my patients.  The past years I’ve travelled the world to help impoverished Africans and Belizeans, and spoiled myself looking at cute babies at the pediatric hospital.   But not all the world is cute or exotic.  Sometimes the people that need the most love are right in front of us in our own communities and are the least cute, the least friendly, and the least interesting cases.  I had forgotten that in my hunger and apathy and boredom.  I’m afraid I’ll only grow more bored and tired and apathetic about what is going on around me as the year goes on.  It is the inevitable fate of most medical students.   My hope that even in the midst of unavoidable apathy and exhaustion, I will still keep my eyes peeled for the important lessons that camouflage themselves in the midst of hungry stomachs and tired feet.  

The Mental Status Exam

            As we all know, strokes are no laughing matter, nor is ending up in the emergency room. 

            It was my first call on my neurology rotation.  Being on call as a medical student means very little, at least on this service.  You work 4 extra hours, from 4-8pm, and you follow around a very frazzled-looking intern as he checks up on all the different patients from the different teams.  My biggest challenge of the night was simply finding the guy with whom I was assigned to follow.  After going to all the usual places, I finally found him in the Emergency Department.  After a brief introduction, he sent my off on my first task of the night—to do a Mini Mental Status Exam on a patient who came in for a stroke. 

            Among the organized chaos of the ED I found the patient in room 7, lying quietly in his bed.  I approach and introduce myself (Introducing yourself as medical student is tricky business.  You can say, ‘I’m just a medical student’ and risk losing all credibility [not that I really have much at this point].  Or you can say ‘I’m student-doctor Katie,’ and hope that gives you a little more credence without the responsibility.) and then began the assessment. 

                        What is your name?

                        What is the day?

                        Spell WORLD backwards

                        Make up a sentence. 

                        Draw these two blocks intersecting…?  ( I didn’t make this up)

            It all seems rather basic, but it does give you a good picture about the possible damage you might be dealing with.  Luckily this guy did pretty well and I had good news to report back to the attendee.  Apparently there is quite a bit more to the assessment, so back we went for round two, except this time asking much more detailed questions as well as examining strength and reflexes.  He was answering some questions right, and some questions wrong, but that was to be expected.

 At one point in the conversation, the resident asked what seemed to be a pretty straight-forward inquiry.  “Sir, what color is the sky?”

The patient looked up at him, a smile slowly creeping onto his face, as he answered, “Well to be honest, doctor, it all depends on the weather.”

I tried with all my might not to laugh too loudly while the resident suppressed a smile with his best effort.  It was definitely not the answer he was looking for, but at least his wit and humor were fully intact. 

It’s difficult to find anything to laugh about in the hospital sometimes.  When people are sick, usually they are really sick.  The rare light-hearted moment amidst all the somber ones can really brighten a day!

July 27, 2013

The 180

You came in for a virus;

A fever,

Some pain in your legs.

There were mosquitos on vacation—

Could that be the reason?

The story was that you were a happy kid;

Excited to play baseball and start first grade.

But your body had other plans.

It turned on you.

There were blasts and there shouldn’t be.

Biopsies.

Blood panels.

Lumbar punctures and ports.

            And suddenly a mother’s worst nightmare was born.

What do you do when the world completely flips?

The only wars you wage now are against yourself.

It’s you against you, but not you. 

The sick kid, the sad parents,

They’re just stories on the radio, the TV.

              The people you see, but won’t be—

Can’t be.

The truth is, Even when,

Poison is the hero and you fight against yourself,

The world is still turning.

Little boys will dream of baseball,

First grade and Spring.

If all goes right, the 180 will become 360,

And nightmares become sweet dreams again.

This is a poem I wrote in honor of my first patient as a third year student. 

It was weird to think that after two years of literally cramming my brain with thousands upon thousands of words and facts and associations and medications, I would suddenly walk into the hospital and be on the care team.  Don’t get me wrong.  I know a lot of things.  Ask me the genetic chromosomal translocation of Acute Pro-Myelocytic Leukemia and I can pull that from its tidy file, but if that patient comes to see me, I’m not going to know what to do about it.  There are just too many dimensions of knowledge in medicine.  I now fully understand why there are so many years of training.   

In the classroom, we would look at the disease and deconstruct it.  What caused it?  What does it look like?  What does it make the patient look like?  How would you treat it? What are the risk factors?  All these random little details that you assemble into a Lego structure and then you have the problem solved and the answer right.  There was a point in my studying where I became so fixated on the facts of the case and the symptoms, I would literally skip the first sentence that described the actual patient being discussed.  He was just a name and an age, what was more important was the disease he had.  That’s all that really mattered.   

In the story of my first patient, I knew the facts, and I knew them well.  I could tell you about the genetics of the disease.  I knew what the peripheral smear would look like that would diagnose him, as well what the mechanism of action of the drugs that would treat him.  But what they just can’t teach you is the way a parent looks at you when they’ve just received some of the scariest news of their life.  They don’t teach you that in the course of one hour a little boy goes from a kid who maybe got a tick bite on vacation to a little boy on the cancer floor of the hospital getting prodded with needles and nurses.  A little boy who now will be at the mercy of poison for years to come.  When you are in the classroom, you have the distance between you and the disease.  You have the safety of pages and pictures that you can simply glance at and dismiss at your leisure.   Now you can’t separate yourself from the patient; glaze over him as unimportant detail.  Because his face, or the face of their spouse, or child, or parent, is the face that is looking right back at you and listening to every word from your mouth as you describe a small detail that could alter their lives forever. 

When you finally reach the hospital as a medical student, you reach the heart of medicine and that is where you will learn the most important details about what this all really means.