Memories

During the first month on my medicine rotation, I met one of the most memorable patients I have ever known. She was a 23-year-old woman with scleroderma who presented to the ER with nausea, vomiting, and decreased appetite. When I went down there to see her, I practically stopped dead in my tracks. She was a textbook example of all the complications of scleroderma, but I was wholly unprepared for what exactly that looked like.

Cachexia is a poor descriptor of the degree to which she was wasted; she barely weighed 80 pounds. Her skin was pulled taut around what little muscle remained. Her gaunt face was accentuated by a small oral aperture, insensitively termed a “fish mouth.” Contractures deformed her upper extremities, with digital ulcerations affecting the distal tips. Large amounts of calcium had deposited along her arms and knees and they constantly elicited excruciating pain. Her legs were wrapped in gauze and hung over the edge of the bed with a special pillow underneath her knees.

Removing the gauze caused such significant pain that it wasn’t until the next day on rounds that I was able to see what was underneath. Her foot had been amputated and a massive non-healing ulcer had formed around her heel, encompassing the entire stump and delving deep into her flesh. Watching her mother unwrap that dressing was a harrowing, heartbreaking experience for me. Instead of screaming in pain—which would have been easier for me to handle—she simply became quieter as her eyes filled up with tears and her mouth transformed into sobs. And she needed dressing changes twice a day.

But despite all her disease, she was a pleasant and gregarious young girl. She was taking online courses at Arizona State. She had gone on a family vacation to Puerto Vallarta a few weeks prior. For all intents and purposes, she had been leading a relatively normal life. That is, until this hospital stay.

Listening to her heart revealed tachycardia. We tried repleting fluids to counteract her decreased PO intake, but all the extra volume would drain out of her leg ulcer and require TID dressing changes. We gave her a Dilaudid PCA to help resolve any pain that might be increasing her heart rate, but we could neither control the pain nor the pulse. We eventually sent her for a CT angio to rule out PE, which again came back negative. Out of options, we consulted a cardiologist who specialized in scleroderma. None of us were expecting the cardiac MR he recommended to show severe ischemic damage with reduced ejection fraction, but that is precisely what happened.

Earlier in her stay we had consulted plastics to examine her ulcer. They were not impressed by visual inspection, but they recommended an MR anyway. The scan revealed osteomyelitis, but her arterial supply was so severely impaired that she would not tolerate a bone biopsy or surgical debridement. She would need 6 weeks of empiric IV antibiotics and follow-up discussion of a possible above-the-knee am­putation (where her blood flow remained strong) sometime in the future.

To make matters worse, she was started on TPN (a poor prognostic indicator) and was still losing weight. We discharged her home from the hospital on my last day on the floor. She was still nauseated and in severe pain, but she wanted to be with her family for Easter Sunday. We were powerless to make her better. Instead we just made her parents all the more aware of just how sick their little girl was. I felt awful.

I took care of her during my entire month on service and she has stayed with me every day since.

Patients

Every patient I’ve taken care of has fallen on a spectrum. On one end are people I enjoy being around. On the other are those patients I dread rounding on each morning. The way I act around these patients also falls on a spectrum. I know for a fact that when I’m taking care of people who smell foul, I spend less time in their room attending to their needs. Likewise, when I’m with someone who treats me well and is easy to get along with, I don’t mind spending a little extra time in their room. That’s just human nature. We like being with people we like. We hate people with putrid odors and those who speak down to us.

During my medicine rotation, I had two patients who were severely demented. One was pleasant and one was mean. Ms. Pleasant had a very demanding family of lawyers. When her son first came in to the hospital, he paged the nurse to talk to someone on our team. I broke off rounds to speak with him, and he immediately asked for “my rank.” Quickly realizing that I had little actual authority, he didn’t hesitate to let me know it: “I need to speak with someone two pay-grades above you.” (Sam joked that two pay grades above a medical student is probably environmental services.) Ms. Pleasant’s family aggravated our entire team and forced us to spend an inordinate amount of time answering all their questions, to the point where we were always working late just to give all of our other patients a fair level of care.

Ms. Mean also sucked away our time. She couldn’t see and felt compelled to have her room phone at arm’s length at all points in time. She made me spend more than 5 minutes adjusting the position on her lap so that she could reach it in the off-chance that someone might call. Whenever I tried to leave, she would always yell at me to come back. Usually it was to reposition the phone or make a phone call for her. Eventually I had to tell that it was not my responsibility. I reminded her that she was in a hospital and not a nursing home. We have lots of duties around the hospital and we can’t spend our time doing those things. I found it really hard in that situation to strike the balance between making sure she was cared for appropriately and making sure everyone else I was responsible for was as well.

The question when it comes to these variable feelings and actions is whether it affects patient care. I certainly don’t enjoy spending my time holding my breath and trying not to grimace, but I make sure I leave with them understanding their disease and why we’re ordering the tests we’re ordering. Even if it takes five different ways to explain something, I don’t ever cut a conversation short if they still have questions. I might linger a little more with friendlier patients, telling jokes or making chitchat, but I don’t ever do it at the expense of other patients. I have yet to break the rules for anybody just because I like them (but maybe that’s because I don’t have any power to break any rules). Still, walking this line will always be a fine balance. There’s no easy way to make sure you’re always doing the right thing. There’s no rule book. Taking care of patients is an art in constant flux.

Complaining

People love to complain. Medicine complains about nurses. Nursing complains about doctors. Surgeons complain about anesthesia. Patients complain about food. Consults complain about getting consulted. Neurology complains about anything and everything. People love to do it, and I’m especially thankful for the people who can do it in hilariously sarcastic fashion. But at some point it just gets old. It ceases to be playful and simply becomes antagonistic. Complaining eventually harbors an atmosphere of negativity and pessimism that is detrimental to team-based care. Worst of all, it reflects poorly on you. It makes it seem like you don’t want to be a physician.

We’re doctors. We should want to help people. We should love doing our jobs. Yes, some families are more difficult to deal with than others. (I’ve had one family member tell me that they need to talk to someone “two pay-grades” above me. I’ve had another tell me her husband was a partner with Feinberg and that “if he knew what was going on here, he would take back this building!”) Yes, some parts of our job are less glamorous than others. But being a doctor is a privilege, not a right.

We are lucky that we can go up to a stranger and earn their trust instantly. We are lucky to be able to break the news that they have metastatic lung cancer to their brain. And we are especially lucky when we can tell them we can cure their disease. We should spend more energy remembering how lucky we are and less energy complaining about how unlucky we are.

But it still goes on. And if there’s one specialty that bears the brunt of all this complaining, if there’s one department that is universally dumped on, it’s emergency medicine. Everyone makes fun of them. Even the nicest people on the planet have a joke on hand to poke fun at emergency. We all understand that their priorities are different than ours, but for some reason it’s still humorous to suggest that they put a CT scanner at the entrance of the ED. If we don’t know why a test was ordered on admission, we just brush it off as being expected from the ED. All these jokes are fun to laugh at now, but what about next year when I’m on the receiving end? I don’t want to be reduced to a stereotype, certainly not a witless and wasteful one at that.

The one reassuring thing I’ve taken from my experience is that people complain about what they don’t want to do. I’m glad the people complaining about emergency medicine are not the ED docs. I just hope the same people who complain at least get energized and excited by whatever it is that they practice. Because who wants to be a Negative Nancy anyway?

Impressions

Impressions are damaging. They’re mocking recreations of others’ peculiarities and speech habits. And I’ve heard more than my fair share of them in medicine.

Now, I’m not sure why the people doing these impressions are physicians, because they’re so good they could be stand-up comedians. They are pitch-perfect facsimiles and hilarious ones at that. And they’re not always negative or bad. (One resident enjoyed quoting my attending Dr. Rosenow by saying, “Rose like the flower, now like right f***ing now.”) But more often than not they’re done out of frustration or exasperation, when they’re tired and stressed, overworked and underappreciated, without any thought to the person they’re aping.

One particular impression struck a chord with me during my neurosurgery rotation. One of our patients was somewhat of a curmudgeon at baseline. He was also hard of hearing. For a few weeks he had been encephalopathic and there was not much to do for him besides daily exams during rounds and fruitlessly attempting to get him placed at a skilled nursing facility.

He had a distinct personality, preferring some residents over others. His responses to our questions of person, place, and time were oftentimes disoriented. Or they were completely unrelated statements. “Where did BETTY go?” he would shout. When I was removing staples from his scalp incision, he would periodically jerk his head and grunt nonsensical sounds. I grew fond of him as the residents grew weary and annoyed.

During down time in the resident conference room, one of the junior residents did an impression of him that was nothing more than loud grunting. The senior resident commended him, “Hey, that’s actually pretty good.” I laughed, although I wish I hadn’t. I felt embarrassed and ashamed, and found it difficult to look him in the eyes the next day on rounds. I had to step outside of my environment, where it’s okay to say and do stuff because I know I’m not being watched or judged, and assess myself. Is this the kind of thing I can stand behind if someone were to overhear me and confront me about it?