memorable patients

I am, I regret to say, quite pleased with myself, which will no doubt get me in big trouble tonight. But for last night, it was great.

They finished with a complex and unusual surgery and took the patient back to the ICU. Somehow he was now my responsibility. The attending and resident left to go home to sleep for a few hours, after leaving me with complex and detailed instructions covering most possibilities.

Of course, as soon as they were quite out of the building, something else happened. He needed a chest tube, or rather, a pigtail catheter. This matters, because I was fairly sure I could do a chest tube, but I had never before seen a pigtail put in (it’s a much smaller tube for draining only air out of the chest cavity, when you don’t expect to find blood, and thus don’t need a large chest tube). The nurses seemed equally uncertain about where to find the supplies, or what to do with the supplies once we had them. Meanwhile the patient’s vital signs became more and more unstable, reminding me very unpleasantly of those questions which occur on every single test from third year medical school up till specialty boards, about the patient with hypotension and tachycardia and absent breath sounds on one side, who will die unless you perform an immediate needle thoracostomy. If you wait and do a chest tube, you always get the question wrong. Now we see why tests are bad for you, because this patient was still ok, but I have seen so many of these questions on tests that I got needlessly concerned about the possibility.

Fortunately at this juncture a senior resident wandered by, noticed the large congregation in the room, and stopped to see what the fun was. He pointed out a couple of errors I was about to make, and with his supervision the catheter got in the right place. (Rather to his surprise, since he seemed not to have done many of these either.) Everyone relaxed. The senior resident left to attend to his own patients. The congregation dispersed.

And then it turned out that the patient had inadequate iv access. Very inadequate. Moreover, nearly every site you could imagine trying was unuseable, for various reasons, including the fact that several attendings had already tried to place central lines, and failed. The nurse, however, continued persistently to fiddle with the lines, and every time I suggested giving him some treatment (because his blood pressure continued to be erratic), she would remark, “That’s fine, but how do you want me to get it into him?” and continue with a litany about how every line was either blown or already in use. So (again with a little supervision) I put in a line, in one of the spots that the attendings had already failed on. That’s why I’m now inordinately pleased with myself; and it’s nice that the senior residents kept walking by and being impressed, too.

I feel like a surgeon. I can do (difficult) lines and procedures on an unstable patient, and be successful, and the patient survived (so far, at least). I made some other decisions, too, which caused the seniors (who were suddenly much more interested in hearing about my problems than they were the last couple nights) to raise their eyebrows and make remarks about clinical indications or the absence thereof – but the morning labs bore me out.

I know that tonight I will get in trouble, because it’s impossible to be so happy with myself, and not make a mistake. “Pride goeth before a fall.” So I remind myself that I was being supervised (some of the time), and that really it was more my good luck that things turned out ok, rather than that I knew precisely what I was doing. Moreover, next year I’ll need to handle, not one, but several critical patients at the same time. This one alone occupied my whole night. I still have a long way to go to being able to balance several ICU’s worth of patients – in four months.

Part of the fun of the night was working with the ICU nurses. They make a great team for each other, always moving to share work whenever anyone’s patient becomes too critical. For this particular patient, since it was such an unusual case, and neither they nor I knew much about what to do, we got along very well: they told me whatever they could remember of “what we did the last time this happened,” and I told them the specifics that I had gathered from the attending’s hasty and detailed instructions, and we did fine.


The other night I wandered into the ICU just to look around. Our vascular surgeons seem to be going through another AAA phase, with record numbers hitting the door in the last few weeks, and I wanted to see how things were going in the ICU.

I found one of the junior residents, Joe, just getting into a difficult discussion with a patient’s family. He was an old man, with a lot of problems, and this time around they had all caught up with him at once. He was in respiratory failure, on a ventilator; his kidneys were failing, and he had already had one round of dialysis; his blood was filled with a raging infection, which didn’t seem fazed by all the antibiotics he was receiving; his liver was starting to look bad; and the monitors were showing more and more abnormal beats, indicating that his heart didn’t have far to go either. The resident explained to me, behind the nurses’ station, that he had received a very frustrated signout on this patient: “He’s in multi-system organ failure. There is nothing we can do for him surgically, or medically either. He shouldn’t even be in the surgical ICU, since he hasn’t had surgery recently. Just make the hospitalists take him, or something. It’s hopeless.”

Joe was not one to take a passive approach. He decided that since no one else had managed to get very far in talking with the family, and since he didn’t want to be the one running multiple hopeless codes on this old man through the night, until finally he didn’t respond to ACLS protocol any more, he would tackle the job of getting DNR status from the family.

I was frankly curious. Much as I hate to think about it, in four months I’ll be the one left over night with four or five ICUs full of patients, and I’m sure it won’t be long before I run into this problem. I wanted to hear what he said. It helps that Joe is about six foot four, with a quarterback’s build. I don’t think I’ll ever make as impressive and authoritative a figure as he does. He told the son and daughter quite bluntly that their father was in bad shape. He explained how all his organs were failing at once, and went through the list of heroic interventions which were necessary just to maintain the status quo. Then he got down to it. “Your father is not going to survive this. I’m sorry to say this, but he is going to die, soon. The question is, how much more do you want him to go through before he dies? Right now, if his heart stops, we’ll do everything we can, giving him drugs and pushing on his chest. It might work for a little while, but it’s not going to reverse what’s going on here.” Within an hour, they signed DNR papers, and the old man died that night.

I believe that what Joe did was good. He helped the son and daughter understand what was happening, probably better than anyone had before. He helped them come to some kind of terms with their father’s impending death, before it happened. He decreased the patient’s suffering, by not forcing him to go through futile codes, and letting him go a little more peacefully. He helped the surgical team, by solving a problem for them.

I’m sure that within a year, I will do the same thing. But right now, I can’t picture it. I tried to imagine the words in my mind, but somehow, despite how much my understanding of “end-of-life issues” has changed in the last eight months, I still can’t make those pessimistic words come out. I still try to think of what might happen well, how things might turn around. I tried to imagine a discussion about “do not intubate” status, which is an oxymoron and a disaster (how can you code somebody, or even try to do pressor support, if you can’t maintain an airway? it’s useless). Some recent tragedies have demonstrated that DNI status simply ties the doctors’ hands. The patient should be either DNR, if everyone is ready to let go, or full code, if it seems like a survivable illness. But whenever I try to put words to that, I find myself arguing for full code. Maybe things will get better; we shouldn’t give up yet.

I think Joe had it on his list for the night: “Check CBC on Mrs. Adams. Serial abdominal exams on Mr. Jones. DNR status, likely death, of Mr. Smith. . . ” Maybe after I run a few hopeless ICU codes, it will be easier to go hunting for DNR status, just another item on a list.

The service has slowed down a bit. When one of our members goes on vacation in a few days, leaving me twice the work, things are scheduled to speed up. I love how that works out. I’m sure it happens whenever I go on vacation, too. That’s why I feel guilty about being away even for one day. Something invariably happens when the team has fewer working members.

There was a lady last week who absolutely drove me crazy. I’m sorry to report this, since she was quite nice, and so was her son. But somehow they were terribly aggravating to talk to. All her previous care had been at an outlying hospital, so we had minimal records. The conversation went something like this:

Me: “Well, ma’am, since you’ve been admitted with a probable pneumonia, do you have any coughing?”
[and please don’t ask me what pneumonia was doing on our surgery service; my attending loves his patients, what can I say? or maybe he just wanted to increase our skill in internal medicine, since this lady seemed to be a walking textbook]
Patient: “What’s that? I don’t hear so good these days.”
Me: repeat three times, enunciating till I feel absurd
Patient: “Oh no, I’m not nauseated at all. In fact, I’ve been eating real good lately.”
Son (yelling): “No, mom, she said, are you coughing?”
Patient: “Oh no, not coughing at all; just my usual, you know, every now and then.”

Some time later, having established that she coughs about five times a day for the last year, not really productive, certainly no blood in it, we’re on to the next topic.

Me: “You’re not coughing, but are you having a fever at all?”
Patient: “Oh yes, I burp a lot. Do you know anything that could fix that?”
Son (yelling): “No, mom, she said, do you have a fever? No, doc, she hasn’t had a fever.”
Patient: “Except for that time, my temperature was up to 100.8. Does that count as a fever?”
Son: “She means last December. Mom, that was when you had the UTI. The doctor means right now.”
Patient: “Oh, no, no fever now.”

A good while later, having established a complete lack of symptomatology, I proceeded to get a past medical history.

Me: “Do you have any medical problems, ma’am?”
Patient: “Oh, no, quite healthy, dear, quite healthy.”
Son: “Mom, you have cancer.”
Patient: “Oh, yes, I do have cancer. It was diagnosed last summer. You see, my legs were feeling a bit swollen, so after my husband and I went on our usual vacation to South Carolina – we go to South Carolina every year. Charleston is such a beautiful city. Anyway, I went to see my family doctor, and he was concerned that I might have a blood clot or something, so – ”
Son: “Mom, she wants to know about what’s going on right now. Tell her about your pacemaker.”
Patient: “Oh, yes, I have a pacemaker, and my heart is doing great, I just got it checked last month.”
Me (sensing a disappearing glimmer of light): “And why did you have the pacemaker put in?”
Patient: “Oh, my heart went a little fast.”
Me: “Was it irregular at all? [to the son] Did she have atrial fibrillation? Do you remember ever hearing that name?”
Patient and son together: “Oh no, not irregular at all. Just fast.”

A long time later, having elicited a medical history containing a disorder in every single organ system, I asked for a list of medications.

Patient: “Don’t you have them in the computer?”
Son: “I don’t have a list, but I know them by heart. Not the dosages, though. She takes lasix, aspirin, coumadin – ”
Me: “Coumadin? Why does she take that?”
Son (with great patience): “It’s a blood thinner. She takes it to thin her blood.”
Me: “But why is she taking a blood thinner?”
Son: “I have no idea.”
Me: “She must have atrial fibrillation. Isn’t that right, ma’am? You have atrial fibrillation?”
Patient: “Oh yes, but it’s been just fine since they put the pacemaker in.”

That was the longest surgical history and physical I’ve done since I was a medical student. Apparently lately all my patients have been either coherent, or so demented that their children were obliged to be intelligible. I’d forgotten what it was like to have a patient too alert to ignore, but too forgetful to be helpful.

Much later, the chief came by to check on her. As he wound up his explanation of our plans and headed for the door, the patient smiled at me from the bed and inquired, in an unconcerned voice, “So then they think it will need surgery?” Since under no circumstances would we do surgery for pneumonia, nor could I imagine what we had said to lead her to that conclusion, I threw a wild glance at the son. “I’m sorry, I have to run, could you please explain it to her?” And dashed ignominiously out to keep up with the chief, who was escaping to see our ICU patients.

I think 8:30 is the latest I have ever stayed in the hospital yet this year. It felt kind of crazy, walking around to check on the patients, saying “goodnight, I’ll see you in the morning,” and considering that “morning” means 4am, less than eight hours away.

But I don’t particularly mind. I picked up a case in the ER, and got to take it to the OR within a few hours, and do a lot of the procedure. Quite satisfactory. Of course it was another one of those ugly, boring cases that no one but an intern wants; but I had fun.

That took till the end of the afternoon. Then, I got called to the ER for an intubated patient. I was trying to figure out what could cause a surgical patient, no vascular issues, to present, intubated. That’s not usually the scenario, when you’re not on trauma. Often enough we have to re-intubate people post-operatively; but to come in like that?

Turned out to be a nice old gentleman, holding his daughter’s hand and nodding at her, in spite of being intubated. His blood pressure was too low to handle any sedatives, and his mental status was poor enough, so he was on hardly any drugs at all.

I got a surprise walking into the room. I started to introduce myself – “Hi, I’m Dr. Alice, one of the residents. . ” – and the daughter interrupted me. “Oh yes, Dr. Alice, I know you!” She’d been identified as a respiratory tech, so I assumed she worked at the hospital, and we’d been together during some crisis or other. I couldn’t remember any crisis involving respiratory which would lead to such a warm greeting, but the patient was in too much trouble to spend time on reminiscences.

Half an hour later, one of her remarks finally clicked. She doesn’t work at this hospital, she’d been here as a patient on one of my previous months. She’d been one of the nightmare patients (the way healthcare professionals often seem to be when they do get sick): the nurses used to argue about who would have to take her, and the senior residents sent me to her room by myself, until something major required their attention. The catch was that I could never relax with her, because she actually was sick, and every so often one of her “crazy” complaints turned into a really serious problem. I learned a lot taking care of her. By the end, though, I did dread getting called by her nurse; but apparently I masked that feeling pretty well.

The whole time that a group of surgery residents spent in the room, working on her father, she kept smiling at me, directing all of her answers at me, and remembering things we’d talked about in the past (when I was being conscientious, and stayed in her room to chat). One of the chiefs was there, big, tall, impressive guy – and she didn’t pay any attention to him, just Dr. Alice.

I feel so guilty. I really didn’t like her at all when she was a patient, and I did my best to stay away from her. She seems totally different, quite a reasonable person, now that she’s better, and taking care of a sick relative. On one hand it’s good that I behave professionally enough for a patient to like me even when I didn’t particularly like them; but I feel bad about being on the receiving end of such good feeling, when I didn’t reciprocate it at all until I felt flattered by her memory and shocked by the difference in her behavior.

Another good day. I was running nonstop (although I admit that my commitment to patient care has declined to the point that I did take ten minutes for lunch, and thus missed a few items of scut, which will keep for tomorrow), and didn’t get much done other than put out fires. Bless their hearts, the nurses had a whole list of jobs for me (reorder the pain medicine, reorder the iv fluids, change the blood pressure meds to po, and so on)  none of which I considered essential except the ones needed to keep the PCAs (patient controlled iv narcotics – very popular with patients and staff) running.

We had a sweet little old guy go into afib with rapid ventricular response. The junior and I pushed some iv meds on the unmonitored floor (to the glee of the patient’s nurse, a very sharp young man, who had initially noticed the tachycardia and brought it to our attention, and the consternation of the nurse manager, who nevertheless had to agree that it wasn’t contrary to protocol if we did it). Eventually the patient stabilized and was moved to a monitored floor. I sent him with very specific transfer orders, and instructions via the nurse giving report, and the nurse who transferred the patient. I thought I could take a few minutes to catch up, and then go over to see what happened.

Half an hour later I called over to check. “How’s my little old guy doing?” The nurse answered, “Oh, I just called the nurses up there to check. Are you going to consult cardiology?” Me (thinking, why would we, we had the rate under control, no symptoms, give us a chance to try chemical cardioversion): “Not right now, no; what’s the rate?” “Oh, 180s.” Me (flying nearly off the handle; or maybe entirely off): “Were you planning to call and tell me that?” Nurse: “It’s ok, it was 160s till just now.” (It had been 90s when I sent the patient over to the cardiac monitoring floor; I thought they cared about cardiac rhythms there!) Me, sarcastically: “Honey, for your information, that’s the kind of thing you’re supposed to tell me about!” I hung up and ran over, to find the nurse blithely filling out useless forms on some other patient. I’m afraid I spoke rather sharply, and told her the forms could wait, but right now we needed to get this patient’s heart rate under control, and go start putting a drip together. He was 85 years old, and had been complaining of chest pain, vaguely, on and off. (And yes, we had done all the tests and medications for acute coronary syndrome.)

Of course, half an hour later, it did turn into a cardiology consult. Turns out the patient was not having a heart attack and is still quite happy and doing much better. Like most of my patients with new onset afib postoperatively, he was more distressed by our concern and rapid activity than by any actual symptoms.

Come to find out that nurse was very senior, and a rather important person on the cardiac floor, and on a first name basis with my attending. Bother, wrong person to snap at. But I don’t care how senior she was, calling another nurse to ask if a cardiology consult is planned is nowhere on the list of things to do when your octagenarian patient’s heart rate shoots up to 180 – or even 160. I would try to talk to her to smooth things over, but I don’t know what to say. I apologize to a lot of people these days; but I’m not going to apologize for that one. I wouldn’t mind if she had called my junior or my chief – but to call the other nurse, and not even mention the heart rate?? [ok, stopping the rant now]

Anyway, in between being concerned for my patient, I was also thrilled. This is the kind of situation that would have completely bowled me over a few months ago, but now I knew exactly what to do, and the senior residents agreed with my plans. (Not calling cardiology at first was their decision, back when the heart rate wasn’t so rapid.) It was still good to have them there checking on me, but it begins to feel as though, in five months, I might be ok to do this more on my own. It was almost like a test situation, there were so many variables, so many medications that we used and tests that we ran, and so many decision points based on the response to medications or results on tests. Now that the patient is ok, I’m almost glad it happened.

For the rest of the day, various other patients went downhill in more surgical and less easily reversible ways. On second thought, maybe there is something to be said for medicine. I know I’m going to offend my medicine friends again, but somehow it’s a different kind of stress to consider what medication to give, rather than whether the patient is going to die without you cutting him open, and committing him to all the risks that that entails. Or maybe it’s just that we weren’t giving enough weight to our consideration of which medication to use. I’m sure if I’d stayed around to ask cardiology, they could have told me a dozen frightening consequences to any wrong choice, that I just wasn’t particularly aware of.

Best call day ever. I got a whole case for myself. Admittedly just a giant abscess, but so disgusting that the attending didn’t even bother scrubbing, just gave vague directions from the background about where to cut, and the senior resident let me dive in on my own. After all, the tissue was so messed up that a couple millimeters deviation in the incision wouldn’t make much difference in the long run. It was neat, because I had admitted the guy, evaluated him myself and concluded he needed to go to surgery (it took me about five minutes, looking at him; the other surgeons took one glance and started calling the OR folks). I had also gone through the consent with him, which was a little difficult, because I knew the abscess was bad enough that there might be complications coming, but he really didn’t want to hear about them: “Just do whatever you need to do, and if it gets too bad, cut my throat.” “Sorry sir, we can’t do that, but I have to be honest with you about the possibilities. . .” It turned out fine. He’ll have some pain, but no lasting deficits.

Then, the computers broke, so the nurses couldn’t check orders, so they didn’t call me for clarifications or new orders for several hours. I got to sleep for an incredibly long time, and study for the ABSITE as well.

At last an ER resident paged me. “Hi, we have this guy here with appendicitis.” Sounded straightforward enough. Except when I walked into the room, the guy was so psycho, at first I was afraid, from his weird symptoms (as he described them) that he had something majorly wrong with him, worse than I’d been told. About thirty seconds later, after three physiologically impossible complaints, my memory of his CT scan kicked in. It had been quite normal, except for the appendix. Then he started talking about voices in his belly, and the government spying on him, and people forcing him to smoke cigarettes, and I knew he was just plain psychotic. I checked for suicidal or homicidal messages from the voices (none; they were just, naturally enough, asking to get out of his belly), and called my senior. I also mentioned to the ER resident that it might be nice to warn people about what they’re walking into when sending them to see psychotic patients. My senior, who hates to admit anybody, even people who are having surgery in five hours, was strongly tempted to call psychiatry on the spot. Since they won’t admit people who have even simple hypertension, I persuaded him that the best thing to do would be to simply proceed with surgery so we could get the guy off our hands as soon as possible. Last I heard, he’d been sent to the floor to wait for the OR to be set up, and was driving his roommate crazy.

This morning, trying to get out of the hospital, I decided that I’m way too successful as an intern. For you folks out there who wonder about my relationship with the nurses, don’t worry. They trust me enough – and know that I’ll be polite enough – that they ask me all kinds of questions. “We have Dr. Alice here, let me just check on that.” “We can handle this patient with xyz bad problems, because Dr. Alice is around. If it was someone else, they’d have to go to a higher level of care; but we know she’ll be available.” “Dr. Alice, your patient in room 3 is complaining about [insert any ridiculous non-problem]. Could you just settle her down?” It makes for good care for the patients, because we communicate a lot and take care of things quickly, but it makes it hard for me to get out of the hospital, or even off the floor.

The other thing that delayed me was a test we’d finally done on a patient who’s just been lingering around, not getting better, several days after his surgery. Yesterday, after having talked with the fellow, I tried to talk the attending into doing the test. He gave me the usual barrage of questions, and although I argued the point, I backed down. Today, the patient was just slightly worse enough that the fellow and I announced the test to the attending as a fait accompli: We ordered it, we’ll let you know the results. It came back majorly abnormal, and now the people on call for the day are going to spend a lot of time trying to fix things. Moral, this attending really is just messing with my mind. Just because he questions my ideas doesn’t mean they’re bad. We didn’t lose anything by waiting a day, except leaving the patient in limbo wondering what was wrong for an extra 24 hours; but next time I’ll stick with my instincts a little more.

We have a young woman on the service now who came to my attending after getting nearly half a dozen surgeries in as many months at an outlying hospital. As far as we can make out from the scans that came with her, from her history, and from the op notes, all the surgeries, from beginning to end, were bases on poor diagnosis, were poorly planned, and poorly executed. She’s left with, among many other problems, an enterocutaneous fistula.

Classically, enterocutaneous fistulas are treated with bowel rest, which means not taking anything by mouth, and depending on total parenteral nutrition for weeks or months until the output dries up and the fistula closes spontaneously. Considering her underlying diseases, this is especially true for her. Her previous caregivers failed to follow this dogma, which is half the problem. (The other half stems from the original bad surgery.) So my attending came and had a very long – and for him, very sensitive – talk with her this morning, about how in six to eight months, we can have everything healed up and put together, and just about all the consequences of this reversed. But eight months is a long time for a person her age. And one or two or three months is a long time to not eat.

I thought she got the point. This afternoon the nurse came looking for me. “Your young lady is asking for something to drink. What are we supposed to tell her about when she can eat – a couple days, you think?” So I explained to the nurse, and then went to talk to the patient. It wasn’t as bad as a cancer talk, but nearly. I thought she’d understood what we were talking about, but clearly not. I went over it all again: what’s the problem in a fistula, how the only way to stop it is to stop the fluid from coming through, how surgery would be a really bad idea for her. For patients who are just in for a few days waiting for their bowels to wake up after surgery, it’s easy to put your foot down and say no eating. I’ve already seen too many people miserable with ileuses when they ignore our instructions, or when we give in and feed them to soon. But for two months? There’s no way anyone can make her do that. She has to understand and decide to do it herself. She didn’t really talk to me, just sat there with tears trickling down her cheeks. Maybe tomorrow she’ll interact with us more.

She’s going to have several miserable months. Her life has been permanently altered by the ill-advised surgeries that were done on her. A surgeon made the mistake, and she’s paying for it. On second thought, I don’t care how long they make me wait to do anything. This is dangerous stuff.

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