Another shoutout to Adam Kay for his wisdom and guidance in all things residency. As a Canadian medical resident, we don't have the requirement to keep a diary of cases and patients, but it is a useful thing for learning and when you need a good cry on one of the many afternoons you just stare out the window. I think I will dedicate this "Memories of Block X" and each subsequent entry of the series to him.
Block 1 (our year is divided into 13 blocks of 4 weeks, each spent rotating through different teams and subspecialties) was on CTU, or the "clinical teaching unit." These teams are variably referred to as "CTU," "team medicine," "general internal medicine," and "GIM." They are a structured environment where residents are on larger teams who admit a variety of patients to their service, which exposes the learner to a wide range of topics, thus enhancing learning. Every hospital has different rules about which patients are eligible to be admitted to GIM, but there are a few solid rules that almost never get broken. You are not admitted to "medicine" or "GIM" if you
1) Are pushing a baby out of your downstairs mix-up. That goes to obstetrics.
2) Are suffering a fracture that needs an operation. That goes to orthopedics.
3) Are experiencing the unfortunate Perforated Bowel. That goes to general surgery.
Those are the easy ones. In some hospitals, subspecialties will *not* admit and oversee a patient directly, so medicine admits them and the specialty in question "consults" on their care. Other times, a medicine subspecialty like gastroenterology will admit patients directly to their service, such as those with a prior diagnosis of inflammatory bowel disease. So here is a quick diary of some notable experiences from Block 1. Patient initials are a complete and utter fabrication.
Mr. A - 74 years old, admitted for multiple falls and reduced cognitive function.
You never forget your first new patient, and boy did Mr. A make an impact, both on me, and the floor on which he walked. You rarely, if ever, meet a patient for the first time without knowing something about them. You are pretty bad at doctoring if you do. As I got the handover from the ER doctor who admitted this patient to our service, a few key words stood out to me: Parkinson's; wife; falls; lawyer; tennis; cognitive decline.
There was enough terror swimming up through my legs with it being day 1 of my new career that I was surprised at the images I conjured of this man I had not met. Was he a former athlete tragically struck with Parkinson's disease? Was he a powerful lawyer refusing to relinquish control of his body to a debilitating disease? Was he a living, breathing Shake Weight with a catheter? I may be an asshole, but please blame the Eternal Fountain of Impulsive Images(TM) for these conjurings, and not my conscious mind.
Even as a student, you equate "Parkinson's Disease" with being at a very high risk for falling. It is a cruel truth that these patients die far too frequently from accidents secondary to the disease (brain bleeds and hip fractures), and not from the disease itself.
This man came to hospital because he went from falling once per week, to fives times per day, and his wife went from "be careful out there!" to "for fuck's sake stop getting up." And that was part of the problem; he refused to alter his activity to match his medical condition. It turns out, his Parkinson's was as optimized as it could be, which brings us to his next problem: orthostatic hypotension.
We have all stood up too quickly and got a little dizzy. It happens, whether you sat in the sun too long, or you just generally have low blood pressure. Orthostasis leading to hypotension is the result of gravity pulling your blood literally into your boots and away from your brain. Your brain says "no thanks" and causes you to pass out and be horizontal. Circulation restored. Most of us avoid this with a complex neurohormonal reaction that tightens our blood vessels and increases our heart rate to send blood to the brain and prevent fainting. This reaction is dependent upon a well-functioning autonomic nervous system. Unfortunately for Mr. A, age, Parkinson's Disease, and Parkinson's Disease medication inhibit this system from working properly. The result is the perfect storm causing severe orthostatic hypotension.
He could be reclining in bed with a textbook blood pressure of 120/70. Model citizen. Have him sit up too quickly and he suddenly transformed into a 90/60 kind of guy. Woozy. Have him stand up immediately and now he's 65/40 and doing his best imitation of a fainting goat.
Here is where I learned a harsh truth about medical management. You are often battling opposing forces, and there is never a perfect answer. Reduce his Parkinson's medication to avoid hypotension, worsen his Parkinson's Disease. Optimize his Parkinson's treatment, and he's flirting with 65/40. I think we also get so caught up in the nitty gritty intellectualization of "solving" this problem that we forget there is always a patient at the other end of our decisions. These patients have a lifetime of identity-building they bring with them, along with hopes, goals, and a family (if they are lucky) that needs to help them manage.
We did what we could for Mr. A., and it still was not perfect. Neurologists, geriatricians, physical therapists, occupational therapists, and social workers all helped us set this man up for the safest, happiest life we could offer him. Bless his heart, he got up and tried to walk out of the hospital on his last day, six weeks later, and still earnestly asked me "what do you think about playing tennis?"
Mr. B - 85 years old, admitted for falls and urinary retention.
I seem to attract patients in bunches, because Mr. B was also a man suffering from orthostatic hypotension (my first on-call shift had me admit three non-operable fractures to our service... I'm really not looking forward to my first patient death). That, however, was where the similarities with Mr. A ended. This gentleman had an extra decade of life, urinary retention, and a Cantonese accent on him.
He always spoke to me in English, smiled, and said "thank you" every day that I saw him. He barely gave half a shit that we were addressing his retention, knee pain, fatigue, and blood pressure issues very slowly. And yet, I felt like at times, I was failing him...
One of the sneakily lazy things residents do with patients like Mr. B is not seek out proper alternatives when communication is lacking between doctor and patient. Mr. B's accent was thick, he had about three teeth, and spent the first few of his days in hospital suffering some delirium, likely due to urinary retention plus or minus low blood pressure plus or minus a UTI plus or minus the generally shitty environment that is a hospital. Communication with him could be laborious. That being said, translation service numbers are at the front of our patient lists, and family phone numbers are at the front of patient charts. There is really no excuse for not clearly communicating with a patient on most days. I did okay on this front, but not my best; his daughter with whom he lived was usually available to translate. However, some mornings the task list staring me down was a bit too long, and some of my other patients were a bit too sick, that I'd settle (and force him to settle) for a quick chat that he may not have understood completely.
By the end of his stay, most of his medical issues were resolved; his orthostatic hypotension was controlled with medication; his sore knee that turned out to have gout was drained and medicated (he was THRILLED about this); his urinary retention was no match for a catheter and a follow-up appointment with urology. And yet, I distinctly remember being a patient in hospital and silently criticizing my doctors for not explaining things thoroughly enough to me.
I feel like some mornings I did Mr. B a disservice by not finding a way to communicate in his preferred language; I cannot tell you how easy and good it feels to breeze in and out of a patient's room at 10:00 AM when treatment is going well and the patient is smiling. And yet, that may have nothing to do with how the patient is doing. "Patient-centered care" is the new buzzword on the block in healthcare, but it truly is important; the next test, or the "cure" that we --the doctors-- think is of the utmost importance, may not actually be the patient's priority. I would do well to remember this going forward.
Ms. C - 53 years old, admitted for ascites on a background of metastatic breast cancer.
Ascites is fluid that builds up in your peritoneal cavity. The peritoneal cavity is essentially the biggest compartment in your abdomen, which contains, or is adjacent to, many abdominal organs and structures, including the intestines. Most circulation in this area has to travel through your liver (via the portal circulation) before returning to your heart. If the liver's vascular structures become compromised, pressure builds up, also known as portal hypertension. Portal hypertension is the commonest cause of ascites, and cirrhosis is the commonest cause of portal hypertension.
Ms. C had ascites due to liver damage causing her portal hypertension. However, her liver damage wasn't due to viral hepatitis or alcohol, as it is for most patients. Her cancer had metastasized to her liver, rendering it fibrotic and stiff. A senior colleague of mine termed it "functional cirrhosis." Not only did she suffer an expanding abdomen due to fluid accumulation, but her legs became swollen as well. She also couldn't escape the biochemical fuck-yous patients with cirrhosis suffer, like low blood sodium (hyponatremia), low white cells (infection risk), low platelets (bleeding risk), low hemoglobin (anemia), to name a few. Life was shit for her on July 13th when I met her, and had been for years preceding this.
All her treatment avenues were palliative. In other words, nothing was done with curative intent. She was going to die, and soon. She knew it, her husband knew it. Even her son, bless his little heart, knew it too. She faced all this with clear eyes, keeping her tears for late at night when family was home. I was on call frequently during her stay; we spoke frequentlyHmm when she could not sleep and her pain medication just wasn't cutting it. She knew she likely wouldn't see another holiday season, and yet her one message to me was:
"I want to fight this as long as I can. Don't give me drugs that will make me drowsy. Get me home so I can be with my family when it ends."
She fought, indeed. She got home the next week, and was readmitted days later with sepsis secondary to an infection of her ascites. The night she came back was supposed to be The End, but some big-gun antibiotics and a shot of heavy steroids gave her the tools to fight some more. Somehow, she was awake and lucid the next morning, asking to go home, and only accepting pain medication that would keep her aware. Our social work and nursing staff, with the help of our palliative team, got her home a second time, this time with a hospital bed, a permanent drain for her ascites stuck in the side of her abdomen, and constant antibiotics to stave off more infections. She died in mid August, surrounded by family, under her own roof. She lost an unwinnable battle, and did it on her own terms.