PGY-3

My last patient of 2014

I’m settling in to the ICU workroom for my last overnight shift, thermos of coffee at my side. We’ve got just five patients — the small blessings of working over the holidays, when elective surgeries are on hold and we just have to deal with the real emergencies: bleeds, clots, seizures that won’t stop on their own. I’ve already stalked the list of patients in the Emergency Department and satisfied myself that there’s no one likely to come to me. Time for Netflix….

Then the junior resident, the one in charge of the floor patients, comes in. She’s just heard about a stroke patient who got tPA at an outside hospital and is being flown to us. Tissue plasminogen activator is a clot busting medicine, developed decades ago and still our mainstay of treatment for acute ischemic stroke. It’s a mega-dose of natural anti-clot compounds, designed to help dissolve the clog in the artery the same way Drano works on shower drains. Then we watch them in an ICU for 24 hours, so we can do hourly checks and make sure they are not getting worse — worse might mean bleeding.  I’ve taken care of so many post-tPA patients at this point in my residency, it’s practically autopilot. I copy down the information the junior’s got — not much, just a name, date of birth, last known normal — and we await our new arrival. This lady’s in her 90s. They tPA’ed someone in their 90s? What were they thinking??? *

The patient shows up surprisingly quickly. She’s terrified, you can see it in her face. Because of the stroke, she can’t speak or move her right arm, but as she’s being transferred into the hospital bed, she reaches out her left hand and clutches mine — freezing cold — and won’t let go. There’s a swirl of people — the flight crew, nurses, me and the other resident. Someone tugs the curtain closed, and she is subjected to the usual indignities. Gown comes half off for an EKG. Swabs of her nose and her rectum (with different Q tips, of course!) because she’s been transferred from another facility and might could be harboring a superbug infection. People — including me, asking her to do a million things, raise this leg, close your eyes, open your mouth, can you feel me touching your arm? Throughout it all, she doesn’t let go of my hand. It’ll be ok, I tell her, you’re in the hospital. You’ve had a stroke. You got some medicine for it. We’re going to get another scan. It’ll be ok. I finally have to wrench my hand away to go back to the workroom and write my note.

She kept me awake for most of the night, that one. First with chest pain. Then with x-ray results. Then with labs being wonky. Finally at 3:30 AM, I’m jarred awake — when did I fall asleep? — by the phone: her daughter calling for an update. That’s when I learn that Ms. TPA was receiving a highly prestigious award (we’ll call it the Badass Award, for confidentiality’s sake) when she had her stroke. It all sounds pretty dramatic, involving foreign diplomats, the press, and paramedics swooping in. So then, of course, I stayed up Googling her — thankfully there’s no mention of the stroke in any of the dozens of local news articles that come up — but I did come across a video clip of her, a week or so ago, talking about the events that merited her the Badass Award. She was sharp and funny — reminded me of a radio clip I’d heard of Doris Lessing in her 90s, telling Terri Gross that she only got married “because biology demands that when a war starts that people should get married and have a lot of sex. As we all know.” (Terri Gross immediately changes the topic, thus proving that Doris Lessing is infinitely cooler.)

There’s something very intimate about hearing a person’s story in their own voice, whether on NPR’s Fresh Air or via a buggy local news clip. This was clearly a lady with a lot of street smarts, now with such a profound expressive aphasia she couldn’t even say her own name. As neurologists, especially as residents who spend most of our time taking care of acutely ill hospitalized patients, we almost never know anything about our patients’ pre-morbid status. The hospital, when you spend so much time there, tends to breed an insular mindset; nothing outside the hospital truly exists. So those reminders, that people lived before getting sick, and they will go on living after being discharged, are so so important to our ongoing training and work.

And so I’m little ashamed to recall my incredulity that “they” at the outside hospital treated my last patient of 2014. Because if they hadn’t, I wouldn’t have had the honor of meeting a woman who had provided so much service, with so few resources, and seen so much.

* More on physician preference (a.k.a. bias) and tPA here. The original article from 2013 is quite good (one of the few that have really stood out from the Green Journal) but hides behind a paywall.

[And yes, I know I’ve been AWOL. I just re-read my earlier posts, and geez I sounded depressed intern year. Residency’s really not so bad; maybe I’ll post more this year to prove it!]

infectious disease · MS-2

Survival

Man.  That pharm exam was brutal.  I came home and slept for several hours, then went to an Internal Medicine/Infectious Diseases dinner, which was pretty amazing.  When it comes to the medicine/surgery divide, I definitely find myself leaning toward medicine (but yeah ok, keeping an open mind for third year). I am just fascinated by the understanding of disease processes, especially how one pathogen can cause a systemic illness involving, say, kidney failure AND pulmonary involvement AND anemia AND AND AND. Once you know what’s going on, it all makes sense. As for Infectious Disease, it’s kind of awesome.  It’s a very open field, in terms of career placement: academic, private practice, international, all of the above.  Also our course in infectious disease is particularly well-run, so that may play into my current love for the field.

(By the way, don’t read too much into my thoughts on different branches of medicine.  At this point, with little clinical exposure, they mostly stem from having had a good lecture.  It’s one of those “Every month I am going to be a different kind of doc” situations.)

I am really looking forward to third year.  As terrifying as it can sometimes seem, I actually find that I learn things a lot better from patients than from lectures.  I’m glad we’re not a PBL-only school, because I would find it hard to extrapolate Grand Truths directly from case presentations, but what makes medicine so much more appealing than, say, grad school is that the stuff I’m learning is directly applicable to someone’s life.  Which, you know, is a lot of responsibility, but it also is probably the best motivator.

And whooosh! off I go to the hospital to learn HIV and opportunistic infection!  from a patient!  exclamation!