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!]

books · narrative medicine · neuro

Dickens and Parkinson

I am making my way through Charles Dickens’ Little Dorrit for a class on the Victorian novel.  The Victorian novel concerns itself with society, not illness per se, so imagine, dear Reader, my surprise at coming across this:

Turning himself as slowly as he turned in his mind whatever he heard or said, he led the way up the narrow stairs. The house was very close, and had an unwholesome smell. The little staircase windows looked in at the back windows of other houses as unwholesome as itself, with poles and lines thrust out of them, on which unsightly linen hung; as if the inhabitants were angling for clothes, and had had some wretched bites not worth attending to. In the back garret–a sickly room, with a turn-up bedstead in it, so hastily and recently turned up that the blankets were boiling over, as it were, and keeping the lid open–a half-finished breakfast of coffee and toast for two persons was jumbled down anyhow on a rickety table.

There was no one there. The old man mumbling to himself, after some consideration, that Fanny had run away, went to the next room to fetch her back. The visitor, observing that she held the door on the inside, and that, when the uncle tried to open it, there was a sharp adjuration of ‘Don’t, stupid!’ and an appearance of loose stocking and flannel, concluded that the young lady was in an undress. The uncle, without appearing to come to any conclusion, shuffled in again, sat down in his chair, and began warming his hands at the fire; not that it was cold, or that he had any waking idea whether it was or not.

‘What did you think of my brother, sir?’ he asked, when he by-and- by discovered what he was doing, left off, reached over to the chimney-piece, and took his clarionet case down.

‘I was glad,’ said Arthur, very much at a loss, for his thoughts were on the brother before him; ‘to find him so well and cheerful.’

‘Ha!’ muttered the old man, ‘yes, yes, yes, yes, yes!’

Arthur wondered what he could possibly want with the clarionet case. He did not want it at all. He discovered, in due time, that it was not the little paper of snuff (which was also on the chimney-piece), put it back again, took down the snuff instead, and solaced himself with a pinch. He was as feeble, spare, and slow in his pinches as in everything else, but a certain little trickling of enjoyment of them played in the poor worn nerves about the corners of his eyes and mouth.

(Little Dorrit, ch. 9)

Frankly, that’s a better description of Parkinson’s disease than I’ve read in any neurologic textbook. James Parkinson wrote “An Essay on the Shaking Palsy” in 1817, when little Charles was still in short trousers. This annoys me, because wouldn’t be awesome if the first description of a disease comes not from the medical but from the literary world? Nevertheless, kudos to Dickens for being so observant.  (And by the way, Arthur Conan Doyle: you are a physician; surely you can do better than “brain fever” when you need to off a character.)