After three blocks on subspecialty services (or Neurology, UGH), Block 6 took me back to General Internal Medicine (GIM). Home base. Familiar territory. My comfort zone. As an overseas graduate, I had been forced into two consecutive blocks of GIM to start the year, which is not something graduates of Canadian schools need to do. This was therefore my third GIM block (already!) and I was feeling like quite the hot shit given that most of my colleagues hadn't even done their second yet.
Ms. L - 81 years old, admitted for sepsis, also had frequent psoriatic arthritis flares necessitating frequent use of steroids.
She was the lady I had spent the most time with, both because of her length of stay, and because of the sheer number of issues she was suffering. She first came to hospital weeks before this admission for a flare of her psoriatic arthritis. In short, she got steroids to settle the flare; those were tapered slowly to avoid a very awkward conversation with her adrenal glands; she was sent home with plans to be followed up as an outpatient.
Unfortunately, she never made it to her Rheumatology appointment because of an episode of lethargy, abdominal pain, and a fever. It turned out she had a urinary tract infection, which led to sepsis (though we never found the infection in her blood... the reason we called it sepsis is.... unimportant), which led to the admission during which we met.
Progressive, unusual back pain lead to an MRI which revealed vertebral osteomyelitis, thus necessitating six weeks of IV antibiotics. We wanted a biopsy of her spine to fully diagnose the infection, but at this point, Ms. L was getting fed up of getting poked and prodded and refused biopsy, so we had to settle for broad, likely poorly-targeted antibiotics. Her stay wouldn't have been complete without another flare of her psoriatic arthritis and another bump in her steroid use making her even more susceptible to infection.
After all this, the hardest part about treating this patient was refusing to partake in the box of donuts her son brought us out of a sense of adhering to food sharing rules related to COVID restrictions. Interacting with this kind, old lady was lovely. Saying no to donuts was not lovely.
Mr. M - 71 years old, admitted for a burst fracture in the lumbar spine, secondary to metastatic prostate cancer.
Mr. M is a common patient; people often get admitted for non-emergent/non-urgent issues because they are unable to cope with their condition at home. That may be due to an inability to care for themselves (due to mental or physical disability), but may also be because the symptoms are too overwhelming to allow them to attend to any other part of their life. In Mr. M's case, pain prevented him from doing anything.
Unfortunately, even if he had been more physically capable, advanced dementia was a barrier to thriving as well. I therefore introduced myself every morning as if we were just meeting for the first time. I also had to appease his suspicions about my intent and reassure him our pain medications, physiotherapy, laxatives, and his room itself, were safe. Most mornings, this was achieved by complimenting him on how much of his breakfast he had eaten. At other times, his palliative care doctor was around (whom he liked far more than me), and I could quietly slip out without discussing Corn Flakes.
Fortunately, Mr. M's cancer was stable and his pain was decently managed. The only reason he remained in hospital for weeks was because we were seeking admission to a shelter that could support his increased needs (his previous shelter being unable to to do so). While patients like these await transfer to a suitable facility (but don't actually require actute medical care) can be a financial burden on the healthcare system, Mr. M is proof we can fix someone's problems, make them feel better, and enhance their quality of life.
Ms. N - 89 years old, admitted for decreased oral intake on a background of advanced dementia.
I like my job; this includes treating, speaking, and generally interacting with patients. And yet, the prospect of walking into Ms. N's room every day engendered such dread as to almost ruin this entire block for me. The stress was entirely the result of her daughter who was at the bedside every morning. This is a person who did not believe her mother's advanced dementia could play a role in her abysmal appetite; the blame was placed on another doctor in the hospital who had cared for her weeks before on a previous admission for an unrelated issue; there was no rationale provided, no medical reason proposed... she simply believed that subpar care on the part of this other doctor caused her mother to stop eating. The idea that her mother had a poor appetite for years seemed to be lost on her.
She therefore insisted on keeping her mother in hospital until her appetite "could be fixed." She also insisted on daily fluids and electrolyte replacement through an IV line when her mother's levels were depleted. She spent 4-8 hours a day feeding her mother 1-2 yogurt cups, to prove to us that we weren't doing enough. Despite this, we as the medical community, were at fault. She refused the proposal to get the Palliative Care team involved, because that would mean we were giving up. The daily fluids necessitated multiple needle pokes every morning because Ms. N pulled her lines out every night. This lead to two separate infections necessitating antibiotics. All this occurred alongside multiple nighttime outbursts of confusion, stress, and hallucinations for the patient in a phenomenon commonly known as "sundowning." (Think of night terrors, but in the elderly)
Ultimately, her belief was that her mother could recover some kind of cognitive function to regain a previously-enjoyed, superior quality of life. Unfortunately, this was never going to happen, and the longer she stayed in hospital, the worse her emotional and cognitive state would become. Once she realized she could not indefinitely spend the majority of each day providing suboptimal feeding to her mother, she demanded a surgical consult so that a gastric feeding tube could be inserted through the skin, directly into the stomach. I left the service before this particular issue came to a conclusion; the nurses on the ward are not so lucky, as they were subjected to abuse from the daughter day after day, as she raged against "the system" and the world seeking a cure for the incurable. Ultimately, it was Ms. N who suffered.
Mr. O - 77 years old, admitted for COVID pneumonia.
Mr. O was my first active COVID patient. His daughter was a colleague, which was both a blessing and a curse. There's nothing like knowing a family member will understand the technical aspects of the patient's care, but also the rationale behind your decision making. There's also nothing quite dread-inducing as knowing the person to whom you're explaining all this to is technically your superior when in a work environment. Next purchase: brown scrubs.
Mr. P - 47 years old, admitted with fever and an infected foot ulcer.
Mr. P was diagnosed with developmental delay as a child. At the time of his admission, he was only capable of 2-3 word sentences, primarily accepting or rejecting attention, whether medical or otherwise. This was partially the reason he had longstanding, poorly-treated non-insulin-dependent diabetes. He had poor vision, kidneys, and balance due to this. He was admitted to our team due to septic shock, the source being an infected foot ulcer which went unnoticed due to lack of sensation in his feet.... due to poorly-treated diabetes.
Subsequent investigations showed the infection had travelled so deeply it had reached multiple bones in his feet. In short, the limb was unsalvageable, whether with antibiotics and/or debridement. The only solution at this stage was amputation. His sister, who was his primary caretaker, understood this. However, his mother, who was his healthcare power of attorney (POA), flatly refused surgery because she knew a family member who underwent something similar with a very bad outcome. Despite countless family meetings, and her son deteriorating in front of her eyes despite maximal antibiotic therapy, she refused.
Meanwhile, the patient himself became aggressive with nurses and doctors, presumably because there were so many new faces each day and he was scared. A few doctors had things thrown at them, a few nurses had been slapped. In my infinite ingenuity, I turned his predilection for slapping into a love of high-fives. We were buds by the end of my time on rotation, and his mom still wasn't accepting an amputation.
Ms. Q - 69 years old, admitted for diabetic ketoacidosis.
Ms. Q was also a patient with poorly controlled diabetes. In her case, however, it was insulin-dependent, and she had poor insulin adherence due to emotional trauma which led to low motivation. In addition, she had a right, below-knee amputation which made ambulation nearly impossible because she was also so deconditioned.
Her pattern was predictable, and happened often: she would present to the hospital in diabetic ketoacidosis (a potentially fatal metabolic state resulting from avoiding insulin use), receive high-acuity treatment in hospital, recover metabolically and physically, and be discharged home with more supports. She would then be neglected by her partner, become depressed, and slip into a pattern of avoiding treatment (primarily insulin) leading once again to diabetic ketoacidosis.
While patients improve their health in hospitals, they are usually quite sick to begin with. Ms. Q was the first person I have met this year who actually thrived while in hospital as compared to being at home.