patient relations

Here we are, on call again. The intern and I are finishing up paperwork in the lounge, waiting for the resident to finish a consult – basically gambling that she’ll finish in time for us all to grab dinner together before another call comes from the ER. Gambling for an hour free on a call afternoon doesn’t strike me as good odds – the ER is going to be cleaning out now – but it’s not nice for only half the time to eat. Either we eat together, or not at all.

I can’t believe I have less than a week of medical school left. This can’t be real. Surely there’s some hoop I failed to jump through, some last test I forgot to take.

Back at the beginning, when they were lecturing us about respecting patient autonomy, and not being paternalistic, I thought it was just a bunch of ethicists’ big words, meaningless, unrelated to real life. Shows me, I guess. Now that I’m out here, I care a lot for getting informed consent – meaning the patient really understands as much as they’re capable of, not that you just got them to sign the paper – and for keeping patients informed and educated about what’s happening. The Indian doctors tend to have a very paternalistic style: “You need to be admitted to the hospital. [Nurse], don’t let him have anything to eat till noon tomorrow. We’ll let you know what the tests show. Any-questions?-no-ok-see-you-later.” Whereas I want to say something like, “These symptoms are concerning for a heart attack, although these lab tests don’t show any damage to your heart, but we’re still concerned, so we’d like you to stay overnight. You’ll have to stay without eating so you can have a stress test in the morning. That will show us how your heart responds to exercise and other kinds of stress, and will give us a really good idea of how much risk you have for a heart attack.” These doctors also drop medical lingo all over the patient: npo, c-scope, ejection fraction, dyspnea, edema, MI – and then conclude that the patient is uncooperative or demented when they can’t answer questions involving these words. I know I’ve come a long way, and don’t understand what the patients feel like that well anymore, but at least I don’t tell them npo (Latin for nothing by mouth), or ask if they’ve had a c-scope (colonoscopy) lately. (It’s funny, though; we really do expect the patients to be as used to being in the ER as we are to seeing them there.)

Last week we admitted a lady who weighs some 300+lbs. I admit that I had difficulty seeing beyond that at first (although I was the one who stuck up for her on rounds, and proved from her old records that her current complaints were real, not imaginary); but after talking with her for a couple of mornings, I realized that she’s a very nice person, not drug-seeking at all (yes, we have nasty suspicious minds around here), who is actually trying to cope with her illnesses rather than just giving up and complaining because no one else can rescue her.

Anyway, after about five days of taking care of her, I started to feel as though I needed to talk to her about spiritual things. I made excuses, and kept putting it off. She was supposed to be discharged for the last three days, and something kept coming up to keep her from leaving.

Finally, I gave in and did what I had been told to do. After talking for 15 minutes about her medical issues this morning, I told her I had been praying for her, and asked if there was anything besides her health that she would like prayer for. She burst into tears and started to tell me all about her spiritual struggles and concerns. We talked for another ten minutes, and I left, thanking God that he hadn’t let go of me until I had talked to her. I would have missed so much if I’d managed to dodge his directions for another day.

This evening as we were leaving the hospital, the resident said of the night float intern who had just taken over from us, “He used to be a very sweet, easy person. He’s not like that any more; he’s becoming hardened.”

And I am thinking: Do I really behave that differently from these other medical people? I join in when they complain about another drug overdose being admitted, and roll my eyes when a patient complains about being asked the same thing for a tenth time, and mock the 300lb lady when she insists that her weight gain of 10lbs over 2 weeks is unusual and concerning. That’s not how a Christian should be behaving. What am I going to be like by this time next year, let alone five years from now?

But how is it possible not to be frustrated and sarcastic about people who come in every month with the same complaint, only being satisfied when they’re admitted and given iv pain medicine? Or people who abuse every drug on the books, and come in every other month with overdose/suicide attempt/psychosis, and thwart all efforts to help them get into rehab?

One of the first medically-oriented books I read as a child was a biography of Mother Teresa. I remember being impressed by how she taught her novices to overcome their disgusted response to the filthy, stinking street people they cared for by thinking of each individual as an opportunity to minister to Jesus, personally.

But it’s hard to imagine Jesus being like these people; he wouldn’t be so difficult, so ungrateful, so demanding, so perversely contrary to all our efforts to help.

The Copts have a great many saints whose legends are taught in Sunday School, right along with David and Esther. There’s Abanoub, the courageous child martyr; and Mina, who left a position of honor and safety in the imperial army to sacrifice his life by declaring his allegiance to the Lord Jesus; and Demiana, who rebuked her father when he denied Christ, and died together with forty virgin companions. (These all died in the persecution of Diocletian.)

Then there’s the story of Abba Bishoi, which must be heard several times before the meanings sink in. Abba Bishoi was the spiritual father of a monastic community gathered around a small oasis in the desert, not far from a mountain range. St. Bishoi was very ascetic in his practices, fasting much, and rising at all hours of the night to spend time alone in prayer. One day, Jesus himself appeared to him, and even washed his feet. St. Bishoi was overcome with joy to see the Lord in person, but he remembered all his brothers the monks, and begged Jesus to appear to them also. Jesus answered that if they would all travel to the top of a certain mountain the next day, he would come and meet with them. That morning St. Bishoi announced his news, and the monks were filled with enthusiasm. They immediately started to run from the monastery up the mountain. St. Bishoi brought up the rear, a little more slowly.

At the base of the mountain, the monks came upon a decrepit elderly man, huddled by the side of the path. As the monks passed, he called out to ask where they were going. When he heard that they were going to see Jesus, he started begging every one who went by to assist him to climb the mountain, so that he also could see Jesus. The monks, in their haste, ran on, saying that they didn’t want to arrive too late and miss Jesus; and anyway, as holy persons who had dedicated their lives to serving God, it was surely far more important for them to get to the top than for this ridiculous old man. Finally, St. Bishoi came to the bottom of the mountain. When he saw the old man, abandoned by all the others, he took pity on him, and, lifting him onto his shoulders, began to slowly carry him up the mountain. Of course, this old man was Jesus himself, and thus only St. Bishoi, who stayed behind to help him, actually saw Jesus that day on the mountain. The Copts always mention St. Bishoi in the liturgies as “the righteous, perfect man, beloved of our Good Savior.”

One of the patients this afternoon came attended by her husband and daughter. The daughter was very sharply dressed, well-made-up, and had a large pad of paper and a pen out as we got started. I thought, “Ooh. Undoubtedly the family is entitled to take notes, and no doubt they will be very well-informed; but boy that would make you watch your words.”

The doctor had to go out to answer a page, and I was left with them, resolving to keep my mouth shut in the face of such a diligent note-taker. The daughter turned to me and inquired, “And who are you?” I thought, “Ooh, I wish Dr. X would introduce me, rather than acting as though anybody who walks in with him is automatically accredited and acceptable.” “I’m a medical student, working with Dr. X.” <bracing for a lecture on unwanted intrusions>

But she and her mother became very friendly, and asked all about whether I wanted to be a neurologist, and how long I’d been in school, and how long surgery residency would be. I’m always smitten with patients who recognize how long it takes to become a doctor; even many nurses think it’s a college course similar to theirs. It turned out that they had a niece who became a pathologist, so we had a nice discussion of career paths in medicine till the doctor came back.

Teach me to draw conclusions from notepads, I guess.

Another patient was a fun chance to practice establishing rapport. This was an elderly lady with her daughter, who started off explaining to me at some length how disgusted she was with her mother’s previous neurologist, who apparently has a computer-based office system, to which this family felt he paid more attention than to the patient. (I don’t know this neurologist at all, so I can’t conclude anything; but all office computers I’ve seen have definitely had a way of observing the doctor’s eye contact and conversation. Even if I am forced to have computers in my office, I won’t put them in the exam rooms.) So I had to try to demonstrate the desired attention and understanding, without agreeing with any remarks about the other doctor, since I don’t know him. Then, once the daughter was happy, and I was trying to ask about the patient’s symptoms, she became very angry, denying that there’s anything wrong with her, furious about having been dragged out to see the doctor, and refusing from the start to take any medicines. So I had to elicit a few key elements of the history from her daughter, and then sweet-talk her into doing the mini mental status exam for me. She had a good reason to be angry; she scored less than 10 on that test (out of 30, demonstrating severe dementia), covering for her complete ignorance of the date and place by saying angrily that she “wasn’t thinking about that,” or “she dragged out me here and wouldn’t tell me where we were going.” I felt sorry for her daughter, who is obviously working hard to keep her mother safe at home, and get good care for her, but is repaid with anger and some really savage remarks.

When the attending came to see them, he was very charming, and the daughter obviously appreciated him (I don’t know what she’ll think after she spends a couple days in his waiting room, but that’s another day). The patient was still angry, but able to appreciate his jokes. I think they’ll be happy with him, and after all that’s about all you can do for dementia, listen and be supportive.

The first patient of the day was an older woman, taking some neuroleptic drugs, complaining of a tremor. I reported to the attending that I didn’t think she fit the picture for Parkinson’s. Of course, after a five minute conversation with her, it became clear from the questions he was asking that he thought she did have Parkinson’s.

The second patient was a middle-aged woman with very marked symptoms, just on one side of her body. The attending’s conclusion was that she has some weird Parkinson-type disease which for some reason is limited to one side (Parkinson’s does tend to start on one side first, but she had had the symptoms for years with no progression to the other side, which would be very unusual). She was kind of fun because her neurological exam was definitely abnormal, and I was able to find the problems. She also had an abnormal gait, which I could see right away (the receptionist could probably tell, too, it was so bad; but I usually can’t make head or tail of gait problems).

The third patient was an older man with a very classic story and physical exam. I announced to the attending, “Ok, I got it this time, it’s Parkinson’s; do you think we can do something different for the next case?” He smiled and said he gave great thought to arranging teaching scenarios in his office schedule. ;)

I do admire his method of explaining the diagnosis. Rather than plopping right out with the name, which would probably be rather frightening to the patient and their family, he starts with an explanation of the pyramidal, cerebellar, and extrapyramidal systems, and how they’re all necessary for normal movement. Then he says that they seem to have a problem with the extrapyramidal system, which could be caused by a disease like Parkinson’s. So he eases into it gradually, and then quickly goes on to the availability of medicines to help with symptoms and retard progression. It takes about ten minutes for the explanation, but I like it; and he tailors it to the understanding level of the different patients, whether they’re relatively young and work in a medical setting, or older and slightly demented already.

The majority of the time, incidental findings are benign, nothing to worry about: small meningiomas, renal cysts, ovarian cysts on CT scans gotten for other reasons, granulomatous scars on xrays, and so on.

But every now and then, they turn out really bad. I think this has to be the worst kind of bad news you can give a live patient: they came to the hospital because of something else entirely, and now you have to explain that because of this test you did, you found out that their life is going to change forever. With other bad diagnoses, at least the patient knew they were sick with something. But out of the blue. . .

When I saw that the admission diagnosis was new-onset seizures, I jumped at the chance to see Anna. Previously I’d seen several patients with a history of seizures, for whom management consisted of verifying that these were nothing different, and adjusting their medications. Anna, on the other hand, would need a complete workup. Twenty-something isn’t too old to develop epilepsy, but it’s unusual.

In a hospital gown, lying in bed surrounded by anxious relatives, Anna looked a lot younger than me, although she’s actually a few years older. The whole time we talked, she looked surprised and bewildered. She’d been babysitting her niece, when all of a sudden she felt hot and dizzy. The next thing she knew, there were EMTs walking into the room. Her older sister had walked in and found her in what sounded like a grand mal seizure. That was it. No risk factors in her family or social history (ie, no epilepsy in the family, no heavy alcohol or drug use recently).

The CT scan done in the ER showed nothing, but just to be thorough, because some causes of seizures can’t be seen on CT, we got an MRI too. That’s when the problems started. When Dr. Army looked at the MRI, he had to recheck the patient’s name and history, because it looked like a prototypical multiple sclerosis MRI. So we went back in Anna’s room and asked a bunch of questions, looking for overlooked symptoms of MS. She couldn’t remember anything significant. Her job has long hours and she’s on her feet a lot, so there’s fatigue and leg pain, but who knows what caused it? Then Dr. Army went over the neuro exam and, being twice as strong as me and more thorough, managed to elicit some left-sided weakness in a few unconnected muscle groups.

So she got a lumbar puncture. Attempted by yours truly, and for once I felt absolutely no guilt about practicing on patients. She needed the procedure (we didn’t make it up for my benefit; hospital lore has it that surgery residents are prone to such proceedings, but I can’t imagine why, since all the ones I’ve ever met have done so many procedures they’re bored sick of them, and would rather imagine away the ones that do exist, rather than create unnecessary ones), and Dr. Army gave me a very careful lecture on the subject beforehand (another reason to love him: he subscribes to the school of not giving the medical student too many instructions right in front of the patient, for both parties’ sakes). I got a lot closer than I ever have before, not running into bone two inches in, but I still couldn’t find the spinal canal. Dr. Army, of course, hit it right away.

CSF studies showed nothing. The particular study for MS, oligoclonal protein bands by electrophoresis, won’t be back will next week. Her EEG looked normal, so Dr. Army gave her the option of going home without any medications, and waiting to see whether she would have another seizure. Of course she jumped at the possibility. He had previously explained to her and her family about the plaques on the MRI, and their probable significance. Anna looked overwhelmed; as if new seizures weren’t enough, she has to adjust to the idea of having a crippling disease, when she felt perfectly well.

That was Wednesday. She was discharged Thursday, while I was gone for Match. I came in on Friday, and got a very bad feeling when I saw her name back on our list. She had come in to the ER overnight, having had a second seizure at home, which her mother claimed had lasted for ten minutes. (Ten minutes is bad; you hope seizures stop in five minutes or so; more than that is a sound reason for calling 911.) Then, after being on a dilantin drip for an hour in the ER, she had another seizure, although much briefer.

She was not happy. Three seizures in three days, after we’d told her she should hopefully be ok for a while – on top of the MS. Dr. Army wasn’t happy either. These seizures were coming too fast, starting too abruptly. He was starting to wonder whether there wasn’t some significance to the MRI findings other than MS. Most neurologists say that MS predisposes to seizures, but Dr. Army is slightly iconoclastic, and he thinks there’s no connection. So the MS plaques and concomitant seizures weren’t self-explanatory, for him. Further workup indicated. . .

That was my last day in the hospital. Next week I’m supposed to be in the outpatient offices. I hope I can track down Anna’s labs as they come back. I hope there’s nothing else unusual to turn up. She’s had enough for now.

You know you’re in medical school when school doesn’t cancel for a foot of snow mixed with ice. No questions, no possibilities: everyone arrives – on time.

After several weeks with private doctors, I am listening with renewed horror to the interaction of staff/academic doctors with their patients. Or rather, the lack of interaction. How is it possible to lead a train of residents into a patient’s room and start discussing certain factors which might lead a person with the patient’s condition to have a very bad prognosis, without really introducing yourself or anyone else, or explaining why you’re there, or what you’re going to talk about?

Today the cardiology team was consulted for a patient with suspected infectious endocarditis. There are a couple possible sources for his infection, which his several physicians are all still rather confused about. The patient himself, when we met him, appeared to have very little idea why he was in the hospital at all, let alone that he had bacteremia, or needed an extensive cardiac workup. Admittedly, he’s not the brightest guy on the block; but he wasn’t comatose, and he wasn’t unwilling to communicate with us. (Except insofar as an elderly man with no teeth and an Indian with a thick accent are hindered in communicating with each other. I tried to straighten out two or three of their most egregious misunderstandings at crucial points in the history, and had to let the rest go.)

The team walked in and out two or three times, and the second attending to be brought in announced to the patient that he needed a TEE (trans-esophageal echocardiogram; better than trans-thoracic for detailed images of the heart, especially the valves), and so would not be eating for the rest of the day, and did he consent to the procedure? The poor fellow looked so puzzled, quite willing to consent to whatever we wanted, but hardly understanding what he was being asked to consent for, let alone why. So I said, He hasn’t really been told about the bacteremia or anything, or why we need to do this test. Dr. B didn’t really appreciate that interruption, but explained briefly that there were bacteria in his blood, and the nature of the test we needed. And the patient agreed.

How could his primary care team not explain the bacteremia to him? How could nobody tell him about the test results that made us suspicious of vegetations, before sending this crowd of cardiologists in to demand more tests? How can you not tell a patient about a situation which could result in emergency heart surgery? Maybe you don’t have to explain at the beginning that he might need surgery, as long as that possibility is still remote. But with such serious issues in play, frequent explanations are pretty important!

So many doctors give overly simplistic (or non-existent) explanations to patients, and then are frustrated when other patients are unable to give them a meaningful history of what happened at the other specialist’s office, or what procedures were done at another hospital a few years ago. If we expect to get any information back from the patients, we have to give them meaningful and digestible information ourselves. Tsk. No doubt these scruples will only last until I fall behind on morning rounds or clinic a few times, and then I’ll be just as brisk as the others. I hope not. I used to hate the phrase, “seeing the patient as a whole person.” But now I understand that that’s just bureaucratese for, being polite to the patient as a human being, not just a pathological specimen.

Looking back through my archives, it looks as though I’ve referenced “my lady,” but never told her story completely in one place. (If I have, sorry, here it is again, and the inconvenient archives here are one reason I’ll be changing sites in May.)

It was a Saturday in the middle of summer, and I was on call, and still hadn’t quite figured out how to keep track of which residents were doing what, or how to sweet-talk the OR charge nurses into letting me see their add-on list. I found a cholecystectomy, watched that, and then the resident (whom I’d just met) suggested that he would be quite happy for me to go to the next case, a diabetic foot debridement, by myself. (I know now that that’s always a bad sign.) It was a nasty case, and I watched on the edge of nausea, while the attending gleefully chopped away with rongeurs (miniature bone-eaters is the best description; they come up bloody, and have to be assiduously kept clean by the scrub nurse – or medical student).

I found the next patient by observing the resident and anesthesia team reading her chart. An elderly lady – not of the bird variety; she would have been tall and strong, before her recent decline. As it was, she lay in the hospital bed, talking nonstop to her tall grandson, a local EMT. We all had some difficulty understanding her, partly because of her heavy accent – she had immigrated from Europe after WW2 – and partly because of the oxygen mask which was necessary to keep her O2 sats anyway near acceptable. The anesthesiologist was unhappy with her pulmonary status, and could barely wait to get back to the OR and intubate her before things got any worse. But first he had to get an arterial line in. This was complicated, because she was on the edge of delirium, and she could not lie still. Watching her, I realized the meaning of the classic description of ischemic bowel: pain out of proportion to the exam; patient moving restlessly, can’t get comfortable. The only thing that kept her from rolling completely over in bed was that her right leg was completely cold and stiff – and had been becoming so for three days before she and her family decided that between that and the abdominal pain, maybe she should see a doctor. It didn’t take the angiograms to tell the surgeons that she had clotted off a significant segment of her bowel, as well as her entire right leg.

As befitted her story, the surgery was epic: to no one’s surprise, half of her small bowel was black. That part was easy to fix. It was her leg which occasioned a lengthy discussion between the two attendings (one had come in from home, not on call, for the occasion). They tried a fem-fem bypass, working in tandem on both sides at once, like master tailors creating a pulsing bridge between the live leg and the dead one. That brought her femoral pulse back, but nothing else. The leg and foot were still cold and pulseless. If they would survive, they would require complete fasciotomies to prevent compartment syndrome, so the resident carefully opened all four compartments with long, deep slashes. This served a double purpose: the muscles could be directly visualized and examined. They were dark, unresponsive to stimulation, and didn’t bleed at all. That was definitive: they had been without oxygen for too long; even the most successful bypass was not going to restore them. The primary surgeon scrubbed out and went to talk to her family, while the rest of us closed her abdomen and the scrub tech got out the amputation set, in anticipation. It was a long time, but finally the surgeon returned: he had persuaded her family to consent to an above-the-knee amputation. She would continue to be in critical condition, but with any luck we had gotten good margins around the dead bowel and the rest would heal, and the bypass was pulsing strongly, and hopefully there would be enough collateral circulation to keep her thigh viable. Technically, the whole leg should have gone. But no one wanted to do that to her: go to sleep for bowel surgery, and wake up with one leg entirely missing. The lower half missing would be bad enough.

She was in the ICU for a week, on a ventilator. Even so, whenever the nurses lowered her sedation, she would be alert, mouthing words around the tube, wanting it out, demanding an explanation about her leg – which she would promptly forget, and ask again in a few hours. Her family was there, taking turns sitting in the room with the matriarch. She had had six children, and grandchildren to match. Although she wasn’t pleased with her situation – she knew she was in restraints, intubated, coming in and out of consciousness, and with a leg missing – she was not unpleasant to be around. She was grateful for all the care she received, and could usually be calmed down with a little conversation and hand-holding.

Eventually she was extubated and moved to the floor. Things were looking up. Her abdomen was healing, bowel function returned, she was breathing on her own. But she never got well enough to leave. Two weeks after surgery, her amputation site was beginning to look unhealthy. Her O2 sats dropped whenever she was on less than 6L of oxygen. When she required continuous CPAP, she was moved to a special respiratory care unit. (Somewhere around here I moved to a different service, and had to keep up with her by dropping in to read the chart and talk to the nurses.) She had surgery again on her leg. She developed pneumonia, and couldn’t be weaned off the ventilator. Eventually, her family decided that her desire for life would not outweigh her desire for independence and dignity. The ventilator was turned off, and she died.

She sticks in my mind. Maybe because she was the first patient I followed all the way, from surgery through recovery to eventual death. But mostly I think because of her powerful personality: although her body was dying, mentally she was strong, insistent, as alert as possible considering her chronic hypoxemia and the sedatives she was being given. Dylan Thomas wrote about her: “Do not go gentle into that good night; rage, rage against the dying of the light.”

I know that every patient I see with mesenteric ischemia will remind me of her, and I will fight fiercely for them, trying to keep them from following her path.

The other night I was at some social event in the area. A girl ran up to me, with beautiful curly red hair, her eyes shining. “Alice! Don’t you remember me?” I must have stared at her pretty blankly, because she went on, “Annie – remember?” People look so different when they’re dressed and made up, not sick and pale in a hospital gown in the middle of the night. It was the girl who had the appendectomy a couple weeks ago, who was so anxious, whom I ended up praying with and holding her hand all the way to the OR. She hugged me right in the middle of the crowd, and chattered happily for a few minutes. I like grateful patients :), but I have no idea what to say to them.

I feel like the best things I’ve done in the last year have been of that type: holding patients’ hands, soothing them through a thoracentesis or an epidural or whatever, when the nurses and doctors are too busy to do so. Those are the things that patients have actually appreciated about me; and soon I’m also going to be busy, maybe too busy and too “macho” to hold hands or spend time talking. I don’t want that to happen – but on the other hand I would like to be the one actually doing the procedure that makes the person better, not just standing and watching.

Just finished my third admission (which makes five patients to see tomorrow), and should be going to bed in hopes of not getting paged again. But I’m too upset about this last incident; so I’ll try to unwind it here as fast as I can. (Details changed, of course.)

10pm: Senior admitting resident, Dr. M, gets a call from the ER attending, that he wants to admit a 2 year old boy with asthma. The boy is a patient of a private doctor, who has the arrangement that the house staff will admit at night, and the intern will follow the patient, and the private will sweep through in the morning to make sure the intern is attending to everything just so. So Dr. M hands me the patient. I go talk to dad, play with the little boy, who is happily sitting in a plastic truck, waving at me, playing with my stethoscope – and of course crying when I touch him. He has no previous history of asthma; his parents noticed difficulty breathing and audible wheezing this morning. He has been feeling better since getting a nebulizer in the ER. Listen to his lungs: I’m already terribly uncertain, because all my lung exams for the past five days have been being contradicted; partly through my lack of experience, and partly when the exam actually does change after I listen. To me, it sounds like increased breath sounds, maybe very soft inspiratory wheezing, all over, as far as I can tell through his crying.

While writing up the H&P, I check the chest xray report: left lower lobe pneumonia. Humph. He doesn’t have a fever; it was a pretty acute onset. But he doesn’t have a history of asthma; the xray report is pretty definitive, not even their usual hedging “clinical correlation recommended.” And even I can see what they’re talking about without too much imagination.

So I report to Dr. M. She shows me how to write up the admission orders, with an IV antibiotic, with plans to keep him for 1-2 days on iv, then switch to oral antibiotics and send him home. Then, she goes to see him. He doesn’t look that sick at all; he doesn’t cry for her, either. When she explains the plan to dad, he objects. He’s self-employed, and recently decided that it was better to save the $750/month he was spending on health insurance, and pay himself if anything happened. Now, reassured that the boy doesn’t have asthma (which isn’t exactly what we said, since he could have asthma brought on or worsened by the infection), he wants to cut his costs by taking him home right now on oral medication. He and Dr. M have a polite discussion back and forth. Her bottom line is simply to say, “That’s not possible. You have to stay overnight now.”

I kept quiet in the room; I do know better than to argue in front of patients. I don’t even suggest consulting the attending. But back in our workroom, I do suggest that the boy isn’t that sick, the oral antibiotic will really do just about as well as IV, so there’s no reason to burden the family’s finances unnecessarily. After all, this is how the free market is supposed to change medicine: rather than doing unnecessary interventions, let supply and demand adjust the pricing, and let patients choose what treatments are worth how much money. Perfect case in point.

But Dr. M explains that, since the ER attending sent the kid upstairs, she is forced to take his word for it that the kid was sick enough to deserve admission, even if he looks better now. Moreover, since she’s operating under the private attending’s name, she can’t just admit and discharge the child, without the attending ever seeing him. Of course, the father could take him out AMA. But she tells me almost pointblank that it would be irresponsible, not to say wrong, to suggest this to the father. Even though she’s just decided that since the father will want to leave as early as possible tomorrow, it will be pointless to start an IV, so she will admit the kid – and give him oral antibiotics.

After “suggesting” till the interns looked up from their work and start explaining the facts of life to me, I’ve reached the point of absolute rudeness/insubordination if I go any further, and have to shut up. The only reason I didn’t work myself into a real ethical dilemma – loyalty to patient or to Dr. M? – was that the father gave a very definite history of his breathing improving after the nebulizer in the ER. Therefore, there is a decent possibility that he has asthma as well as pneumonia; so if he goes home, he will get worse again in a few hours without the nebulizer, and be right back in; which would do no one any good.

Dr. M called, not the private, but the distantly related private who was covering for the first one. This doctor obviously refused to take any responsibility, and recommended keeping the patient overnight. On oral antibiotics.

So here we have the absolute failure of a system, built around the assumption that all the residents’ patients will be covered by Medicare, and we can charge the government for any wild test we want, and that the best way for the ER doctors (and also the house staff) to avoid getting sued is to admit at the drop of hat – and sometimes just at the wave of a hat. Everyone is happy, except for responsible, independent-minded folks like this father, who are penalized, not just through taxes, but through personal costs, for the irresponsibility in society.

I apologized to Dr. M and acknowledged that she was ultimately responsible for the patient, and she said, she’s equally upset about the situation, patient should not have been admitted, we now created useless work for her, and for the interns tomorrow.

So the question is: when I’m a resident, will I stand up to the attendings and refuse to admit patients? Do you think I can succeed in being labeled uncooperative and disruptive even before finishing residency? (This is how medical boards typically get rid of the maverick doctors in a hospital system who try to buck the established methods when they see problems hurting their patients. See AAPS, on my sidebar, for more; too tired to hyperlink!)

The day team handed off a clean board yesterday evening. The first girl in triage was 17 years old, at term, her first pregnancy, complaining generally of contractions. Upon examination, she turned out to be 7cm dilated, with a bulging bag. In other words, farther than most multigravidas get before coming to the hospital. And, to top it all off, she wanted no epidural. Two hours later, without further interference on our part, she delivered the baby. I tried to help, but the intern must have gotten cold feet at the last minute, because he elbowed me out, until the head was out, whereupon the attending exclaimed, “Let Alice do it!” Do what, I wasn’t sure. Apparently the anterior shoulder was already out. Did you know how long a baby’s legs are? You have to pull up an awfully long way to get them all out!

Well, it turned out that the poor girl had two separate tears; it was a decent-sized baby. Now, repairing tears in a woman without an epidural is a nasty business. With an epidural they still feel something; without, you simply have to lie continuously, saying it won’t hurt much, and you’re almost over, when the opposite is manifestly and instantaneously the case. The tears were bleeding, and they were big enough to make a mess if not fixed. So the intern very wisely paid no attention whatsoever to the patient’s complaints, once he knew he’d injected lidocaine as well as he could, and simply stitched away, without saying anything. I was very concerned by her; and if I had been trying to sew up, it would have taken twice as long, being distracted. (Although I must say, I wish the baby nurses would show a little discretion. The only times she didn’t complain was when she was holding the baby. So part way through the nursery people came, and insisted on taking the baby, to wash it and what not. Why couldn’t they have waited five minutes?)

Around 2am a private doctor called the intern to assist in a Csection, and I tagged along. The lady was very nervous, and kept jumping and exclaiming, though the surgeon had carefully proved that she didn’t feel the sharp instruments at all. She was just so excitable that she exclaimed over every movement she felt. At first he tried to reassure her and go slowly, but once the first few cuts had been made, neither the attending nor the intern paid any more attention to her. Which was quite necessary, because once you start, you have to get the baby out quickly. It would have been harmful to both mother and baby for the surgeons to be distracted at all by her exclamations. Nevertheless, we were all relieved when the baby was out, and the anesthesiologist could give her some “happy medicine,” whereupon she began chattering happily instead of nervously.

And finally, the ultimate example of ignoring the patient, in a sense, is a major surgery. The surgeon somehow separates the personhood of the patient from the actual body in front of him, so that he can do all kinds of awful things to the body, without feeling as though it’s related to the person. Having a drape over the patient’s face helps with this, of course. So does the whole protocol of the OR. While the patient is conscious, you pay attention only to them, speaking in whispers if not addressing them, and hurrying to do everything needed to get them on the table. Once the anesthesiologist asserts that they’re asleep, everyone starts talking louder, laughing, joking. It’s as if the patient has left the room. During the surgery, attention (except for the anesthesiologist’s) centers on the surgeon: do whatever he says, jump when he says, listen carefully to his orders. But as soon as the attending rips his gown off and the anesthesia begins to wear off, the attention is back on the patient. They’re real again, now, and we talk carefully of and to them. And I think that’s the only way you can do surgery; I couldn’t bear to have the mental construct that the violence of surgery was directed against a real, friendly person. Which makes the anesthesiologist a magician.

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