Internal Medicine residents are not often thought of as being better off than other first-year, non-surgical residents (surgeons are masochists, and should be both applauded and chastised for their life choices). Regular days are generally longer; there is a greater total number of call shifts; despite herculean efforts by most programs to improve resident wellness, there still remains a hyper-competitive aura that often pushes residents too hard.
There is, however, one aspect of my curriculum that I can take solace in. Only one of my thirteen blocks in Year 1 is "off-service." Off-service blocks are those not considered within the specialty in which you practice. These are necessary to satisfy the curriculum, but are often considered difficult because they place the resident farther out of their comfort zone. This means twelve of my thirteen blocks are either General Internal Medicine blocks, or subspecialties in the field (e.g. Cardiology, Respirology, etc).
My one off-service block this year was during Block 4, and it was Neurology. Let me make something clear: I hate Neurology. Its science is laborious to learn, its pathologies are tedious to treat, and everyone is smarter than me.
Ms. H - 94 years old, seen in the Emergency Department for a stroke.
Constantly standing in the shadow of Neurology residents is bad enough, but being on call for the Stroke Team is the turd that tops this shit sundae. There is a 0% chance of having a quiet night, and the expression "time is brain", which has been hammered into your head since the first day of medical school, is going off in your mind like a Las Vegas sign every time the pager rings.
Strokes are like heart attacks, but in a different organ. A travelling clot (embolus), or a local narrowing (stenosis if chronic, thrombus if acute) will cause the blood flow to a portion of the brain to shut off. The affected tissue will become ischemic (oxygen starved), and if this goes on long enough, infarcted (dead). The longer the wait before intervening, the more brain tissue will go from ischemic (reversible) to infarcted (irreversible). Time is brain.
One night, I had admitted two patients who came through the Emergency Department (ED) with strokes before 10PM. The evening was hectic, but I was well supported by the Stroke Fellow, who ultimately makes most of the decisions. Both patients were tucked in on the ward by midnight, and all my orders for the next day were entered. I felt like the karma was on my side; I had done good work and with sufficient volume that there was NO WAY I would see more patients that night. Right?......
Wrong.
I was in bed at 00:30, watching my requisite three episodes of New Girl to calm my shit down before trying to sleep. At 02:00 I was starting to get that dizzy woozy creamy sleep feeling as my soul screams LET'S FUCKING GOOOOOOOOOOOOOOO to the sheep. Of course this is when the pager goes off. I get a simultaneous text from my fellow: CODE STROKE: 94F, last known well time 07:00, L sided weakness from *** Hospital.
My shoulders slumped even as I was rocketing out of bed. A person this old, who was last seen well almost 24 hours prior, would be a very unlikely candidate for both the heavy-duty blood thinner that is beneficial in some strokes, or the procedure whereby we thread a wire up to the clot and physically remove it. We went through the motions... examinations, blood tests, CT scans, only to find what we already knew; her combination of age, time since the stroke began, and location of the stroke made the potential risk of intervening greater than the benefit. The treatment in this case would be conservative blood thinners like aspirin, and cholesterol medications. Because we weren't able to offer any more treatment other than conservative medications, protocol dictated she was to be repatriated back to her "home" hospital (she was sent to ours from that hospital because we were a specialist stroke center).
Medically, this was frustrating. Here is a woman who was previously walking and talking, who now could not do either, and science said we had no more treatments to make her better. Procedurally, this was a piece of cake. I didn't have to admit her to our ward; all I had to do was make one phone call back to her home hospital and hand her test results and report to the clerk. They would book her ambulance back and I would never see her again.
The one wrinkle during COVID is that transport services are busy, even at 03:00. The earliest transport available was for 14:00, a full eleven hours later. This is highly unusual, even during COVID. The trouble was, this patient was not admitted to a ward. She was stuck in the ED, in limbo between two hospitals. The ED staff had not attended to her in over two hours because the Stroke Team was taking care of her. At this stage, they had "handed off" the patient to us. She was no longer their responsibility, but ours... mine. Our attending staff had been comfortably in bed; our fellow had gone home; our resident (me) was left to tidy up. At this stage, I knew that if I went upstairs to bed, this woman would lie in a bed for eleven hours, relatively unattended, waiting for transport back to her home hospital.
I cannot explain to you the guilt one feels when, even for the briefest moment, you weigh the thought "my job is done" and walking away, versus spending time to make sure a patient is comfortable until discharge. The thought crossed my mind. Did I mention I hate Neurology and simply being on this rotation? I went and stood by the bedside.
For the first time that night, I had a chance to speak to her for more than ten seconds at a time. She looked at me, but also past me. She seemed to be focusing on nothing at all, her lips parting slightly and then closing, almost as if she wanted to say something but had no words left in her mind and no strength left in her body. I adjusted the angle of her bed, and her blanket, brushed her hair out of her eyes, and watched her simply exist, powerless, in a dark corner of a busy emergency department. After walking and talking on this Earth for over ninety years, a stroke had taken all of it away in ninety seconds.
I had a sudden urge to give her something to sustain her... food, water, anything, but stroke patients are at high risk for choking. I asked a qualified nurse to administer a swallowing exam that helps determine if a stroke patient is safe to eat. She failed it immediately. I searched her chart for a phone number to see if I could contact family or a substitute decision-maker; she had neither. All I found was a number to the nursing home where she lived.
I wanted to go ask the nurse to keep an eye on her throughout the rest of the morning, but I knew that would only mean an hourly walk-by to check the vital signs on the screen. I found my feet stuck to the ground, as if in cement blocks. My legs had planted themselves of their own volition by the bedside and I was powerless to move, as if roots emanating from my feet were racing to the center of the Earth. I could not take my eyes off her. She was alone, completely and utterly alone. I began to lament how lonely she must feel, but she was less than alone. She likely could no longer fathom the concept of "alone". She was an N of less than 1 now that this disease had wiped away most of her mind.
Your mind betrays you in moments like these. You get absurdity..."What if I had a stroke walking up the stairs later? I hope I'd still be able to eat, at least." You get selfishness... "I really could be in bed right now." You get anxiety... "There is no reason I couldn't be in her position when I'm older." You get sadness... "I wonder what she's thinking. Is she thinking? I know this is 'being alive,' but is it really?" You get distracted... "Ooh it's Thursday, new Loblaws coupons." And yet, every time I would snap out of it, she would be right there, unmoving, staring over my shoulder, forever trying and failing to say something. I felt like I could stand there forever, brushing hair out of her eyes, not because I wanted to, but because I was powerless to do anything else.
I still think about Ms. H months later. I am not sure I will ever be able to stop the thoughts of standing by her bedside for minutes (hours?) on end. I honestly do not know how long I stayed there, but at some point I went upstairs to the call room. I didn't sleep. I just kept thinking "it is not good to be alone, it is not good to be alone." It does not feel traumatic the same way watching my first patient die was. It just feels poignant. There are so many moments since then, at work, where my mind will simply say "hey, remember Ms. H?" and I will end up adjusting how I am doing a particular task as if she would apprecaite me taking more care at it. I guess that is what experience is; I guess that is how you learn; all I can think sometimes is, it is not good to be alone.