memorable patients

The other day in the ER I had one of those patients whose family is so grateful, it puts you at a loss for words. The wife and son had brought in an elderly man, who had been in pretty good health until he was diagnosed with a dangerous cancer. Although the surgery had been done at the beginning of the year, he was still in the process of recovering. They had thought things were going well, and had in fact been travelling together to visit family in another city, when he began to show signs of a stroke: tilting off to one side as he walked, slurring his speech, not remembering what had just happened. Although much too late to make a difference if it was a stroke, they stopped the trip in our city and brought him in to the hospital.

(Public health announcements: 1) Jump out of burning buildings, don’t walk/run through them. 2) If you or a family member may be experiencing a stroke, go get it evaluated. We only have a window of three hours from the start of symptoms to be able to make a difference. Although 80-90% of stroke victims don’t qualify for the “clot-busting” drugs; but you might as well have a shot at it.)

Our ER prides itself on activating stroke alerts and moving quickly if there’s any question of the patient having a stroke and/or being in the time frame to benefit from emergent intervention. So the full court press that the family encountered – straight from triage into a room, ivs and labs, EKG, doctor (that’s me) evaluating them within minutes, CT on the spot – was only our standard protocol. Nevertheless, after hours of watching their loved one closely, becoming more and more frightened for him, and finally landing on the closest ER in despair, the wife and son were almost tearful with gratitude. I need to think of something more gracious to say than, “We’re just doing our job.” It’s true, but it’s not the whole truth. We were happy to have a chance to do our best for him.

He turned out to have a sodium somewhere down around 108. (Normal is ~140; you start getting neurological symptoms ~125.) For a few minutes I was afraid that the ER attending was going to demand from me a treatment plan for severe hyponatremia, seeing as how the ICUs were pressuring us not to admit anyone else for the night. At the moment, my thoughts on hyponatremia could be summarized as 1) bad; 2) dangerous; 3) fixing it has to do with normal saline and/or free water restriction; 4) bringing it up too fast is even worse, because it can induce central pontine myelinolysis, which is irreversible damage to the brainstem; and I didn’t want to be responsible for that. Fortunately, as news of the lab result circulated around the nurses’ station, the ER residents started quoting one of the attendings: “The treatment for severe hyponatremia in the ER is . . . admit to the MICU!” I heartily agreed; and for once, bed control was on board, and we got him out of there. (There is a formula for calculating how many milli-equivalents of sodium a patient is lacking, and a formula for arranging to replace that at a rate of 0.5 meq/hr; but it’s not inside my head.)

Today for the first time I told a patient that he had cancer.

I’m angry with myself, because I didn’t do it the way that I had always planned to. I didn’t ask what they’d been expecting, or break it gently, or hold his hand or his wife’s. I went in to talk about how he’d need to be admitted to the hospital, and how we’d be consulting these different groups. His wife said, “So then you think there’s something wrong?” And only then did I remember that they didn’t know.

After all, it was obvious to me from the moment they walked in. Two sentences of history from the man, and I knew it had to be cancer. The physical exam completely confirmed it; the signs were all there, glaringly obvious. To my mind, I ordered the CT simply as a formality, a box to check off before I could call an admitting physician and say definitively that the patient had cancer. There was really nothing else it could be. They’d been sent in urgently from their family doctor’s office; of course he knew what it was too, and he just wanted us to run the CT scan and admit the guy for a workup before starting chemo. Somehow I thought the family doctor would have given some clue, that between his deep concern and the unmistakable symptoms, the man would have had some idea of what was coming.

But no. “Do you think there’s something wrong?” Yes, I’m sorry, it’s bad news, but you seem to have a mass. It’s most likely cancer. I’m sorry. “What about a blood vessel bleeding? Maybe it’s just inflammation?” No, honestly, I know we only have a basic CT right now, but there’s nothing else it can be. With the story you’re telling me, and what we saw on the pictures, it really is cancer. I can’t say what kind, we’ll need more tests, but it is cancer. [I called the radiologist, but I didn't need to; even an intern can recognize that shape.] “How about if we go home, and come back tomorrow?” (They’re in denial now, and I can’t blame them; they’re hoping it might go away overnight; perhaps at a different hospital the tests will come out differently.) No, I’m sorry, your symptoms are moving quickly enough that we’re not comfortable sending you home. You need to be in the hospital for observation while we do more tests. [It might not be safe for you to be at home.]

And the whole time, I was itching to get out of the room, not even really going slow enough, or being sympathetic enough (how can you be sympathetic enough when you give someone a death sentence?), because I wanted to get back to the phone to get started on the long slow process of tracking down their family doctor (why do you send someone who obviously has cancer to the ER to get admitted for a workup without telling anyone – hospitalist, oncologist, ER attending – that you’re sending them?) and pinning down a hospital team to admit him. In the end it would make that particular night a little easier for him if I could get him a bed before midnight – but it would also get me out of the ER a little closer to the end of my shift, rather than three hours later (as it happened).

I was so concentrated on the mechanical business of arranging the admission that I even followed the textbook (give them a minute to think about it, to let things sink in, then ask if they have questions), answered the questions, behaved as empathetically as possible, and was out of the room, before I realized what I’d done: I diagnosed someone with cancer, and told him about it. His life changed forever in five minutes, and I wasn’t even paying attention. I’m a paper-pushing machine, not really a doctor; this isn’t right. I hate the cancer for existing, and myself for doing this wrong. (And underneath, I’m happy that I got the diagnosis right.)

This blog is getting way too boring, with no stories in it. Sometimes exciting things happen to me, but you’d be surprised how spread out they are. (At least, things that you’d consider interesting. I got to tie about a hundred knots today, and have half a dozen cases to put in my log for the last week, both records since the start of the year. But you don’t want to hear about how much fun it is when the needle slides in right where you want it, and when things are flowing smoothly enough that you can sew and tie faster than the attending.)

Awhile back, I met one of the most fearsome attendings at this hospital. He’s the kind of person who makes you wonder whether it’s worse to go to conference, and get chewed out in front of a large audience, or skip conference, and get massacred in a more private setting. (Thank God I don’t belong to his program, so I don’t have to worry about it too much.) He’s the kind of person the whole OR talks about behind his back, the kind who can get large blocks of employees to quit en masse.

The whole team of us were knee-deep in a burn case. The wounds that needed eschar (which is medicalese for scar) excised (cut out) and grafted with healthy skin were widely scattered, making room for a couple of interns and medical students to be busy at the same time. For a change, we had a happy scrub tech, one who wasn’t furious at having more than three people scrubbed in his case, and who actually thought ahead and asked for supplies before we needed them. The circulator and anesthesiologist were also quite chipper, and we were having almost a party in there. (It was also quite late, and we had gotten to the point of abandoning thoughts of going home or doing anything when we get there, which creates a kind of happy-go-lucky spirit.)

An older man walked into the room, half-holding a mask over his face. “Dr. Smith! I found your room. How’s it going?” He walked around the table, peeking over our shoulders. “This is quite a case you’ve got here. Those are extensive burns. How much, exactly?”

Since I’d admitted the patient, I felt that the question belonged to me. I wasn’t sure who was asking, but he looked like he had a right to ask – maybe one of the anesthesiology attendings checking to see how long till the room was freed up. “Well, what we wrote on the admission sheet was 20%. Something like that. It’s hard to tell, because it’s scattered all over like this.”

There was a pause. “Who was just talking to me?” he inquired, in a nonspecific tone of voice. Dr. Smith introduced me as rotating resident. Our visitor continued to circle the table, greeting the other residents and students, whom he knew. Then he asked, “So what kind of a fire was he in?” “There was no fire,” I blurted out. “Oh, I’ve got everything wrong today, huh?” he said. “Come on then, what was it, if not a fire?”

I could tell I’d missed something, but it was too late to draw back. “He was working in a factory, when a piece of machinery malfunctioned and spilled a ton of boiling water on the floor. He slipped and fell into it.”

The visitor nodded. “I see. And what’s his medical history? That looks like a chevron incision there.” [typically used to gain access for major liver surgery] “That’s exactly what I thought when I admitted him. But he told us he was injured by a knife when he fell down a flight of steps some twenty years ago. He was carrying a lot of laundry, you see, and there was this knife – I think it was left lying in the wrong place, or something – anyway, when he fell, it somehow ended up perpendicular to his liver. He had to have a formal resection to stop the bleeding.”

“He seems to have a knack for falling in the wrong places,” our visitor remarked before strolling out. And from the conversation that followed, I realized he was the notorious attending I’d been hearing about all month. There’s nothing like not knowing what you’re getting into to make an intern talk smart to a senior attending. Good thing I didn’t belong to him.

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