The first time I met him was briefly outside the OR before his surgery, in the pre-op area. I introduced myself as the medical student on the team, and he pleasantly smiled back at me. He didn't seem too nervous. There could be a few reasons for that. He had gone through this before; he knew what to expect. He had also been in the navy, as I learned later, and had probably faced a lot of things worse than this surgery. Lastly, he had gone through extensive chemotherapy and radiation, which is difficulty for anyone. So, although he was undergoing a rare operation, one the chief resident had never seen and the surgeon, a leader in his field, had only done a handful of times, he was calm.
It was a long, complex surgery. First, one surgical specialty team did their part, and then, three hours later, my team came in to do ours. During the surgery, we kept getting positive margins, which means cancer cells are present, on the specimens we sent off to pathology, so we kept resecting until we could resect no more. Luckily, that last margin was negative. I remember feeling good. It was a really cool surgery and we seemed to have gotten our desired result. The other team then came in to finish their part. Twelve hours from first incision, it was done.
For the first few days after the operation, he seemed to do pretty well. He was sore, but recovering. I got to meet his family and learned a little more about him. We celebrated together when the final pathology came back negative.
Post-op day seven, things changed. He started spitting up what appeared to be bile. We tried to give him some medicine to help his intestines move things along, but it only made him severely anxious. We ended up scanning him. Something was wrong and his new intestinal conduit wasn't emptying properly. We presented him at tumor board that day. Tumor board is a meeting where all the specialists in that field get together and review cases. The decision was made to take him back to surgery that night. After 2 hours of making little adjustments, but not really finding the cause of the problem, we closed him up. He was in the ICU for a while after that.
The last day of my rotation, we were getting ready to transfer him out of the ICU to the regular floor. I remember reassuring his worried wife that he was on the road to recovery and didn't need to stay in the ICU anymore. I was wrong.
It is now a month and half later, and he is still in the hospital, in and out of the ICU, in and out of the operating room. To quote author, Chinua Achebe, "Things Fall Apart," and based on my medical school experience, it always seems to happen to the nicest patients.
The reason I like surgery is that it was one of the most concrete ways to help a patient. An appendix ruptures, you take it out. Problem solved. Unfortunately, it is not always that simple. Sometimes you end up hurting patients more than helping them although your intentions were otherwise.
Friday, June 14, 2013
Monday, February 25, 2013
In honor of the name of this blog...
http://whatshouldwecallmedschool.tumblr.com/post/43977142745/my-main-issue-with-see-one-do-one-teach-one
Somedays you can jump the pole after seeing it done, other days you can't :)
Somedays you can jump the pole after seeing it done, other days you can't :)
Favorite Patients
One of the authors of my favorite blogs, http://www.gradydoctor.com/, talks about her "FPs" or favorite patients. These are the patients that just find an extra special place in your heart for one reason or the other. I've had a few FPs, most of them on the medicine rotation. One of my FPs was the patient discussed in the last post (FYI: who recovered well and is now continuing chemotherapy).
My FP this month is an 83yo lady who was admitted for bloody diarrhea. She is just the cutest LOL (little old lady) ever. I hope I look half as good and I'm half as sweet when I'm her age. I could always walk into her room in the morning expecting a cheerful "good morning" accompanied by a smile. Despite being in the hospital, she took care in the way she looked. She had always showered (not the case for a lot of our patients), combed her hair neatly back, and even had some flowers and nick nacks decorating her room. She had the sweetest way of asking me questions and would always ask if I could update her daughter.
I walked in today and she was on her laptop!! An 83yo sweet, smart, tech-savvy lady -- impressive. She then proceed how she was going to TEXT her daughter to pick her up later in the day -- text! I was so impressed, and I told her so. She was just such a breath of fresh air. 83 and not letting anything keep her down, ready to face the day, and taking on any challenges life might throw her away, including texting ;)
My FP this month is an 83yo lady who was admitted for bloody diarrhea. She is just the cutest LOL (little old lady) ever. I hope I look half as good and I'm half as sweet when I'm her age. I could always walk into her room in the morning expecting a cheerful "good morning" accompanied by a smile. Despite being in the hospital, she took care in the way she looked. She had always showered (not the case for a lot of our patients), combed her hair neatly back, and even had some flowers and nick nacks decorating her room. She had the sweetest way of asking me questions and would always ask if I could update her daughter.
I walked in today and she was on her laptop!! An 83yo sweet, smart, tech-savvy lady -- impressive. She then proceed how she was going to TEXT her daughter to pick her up later in the day -- text! I was so impressed, and I told her so. She was just such a breath of fresh air. 83 and not letting anything keep her down, ready to face the day, and taking on any challenges life might throw her away, including texting ;)
Saturday, January 26, 2013
Free Air
Free Air.
Two words you never want to hear, specifically if it's followed by the phrase "under the diaphragm." You hear that, and it can only mean one thing... straight to the OR for an exploratory laparotomy where you get a vertical incision all the way down your belly to explore your abdomen for the cause of this "free air." Free air means that something has perforated or ruptured. Never good.
That patient I mentioned in my last post? My first patient on this rotation? The one I had to tell he had lymphoma? On of my FPs (favorite patient)? The one that was finally starting chemo and getting ready to be discharged? That one? His xray yesterday showed free air.
Every morning I walk into his room to ask him how he's feeling, and before I can even get the words out, he'll ask "How are you doin' this morning?" And he genuinely wants to know. Every evening when I check on him before I leave, he tells me to "you drive safe." Yesterday morning I walked into his room, and he told me about this belly pain. This belly pain that felt different from his normal belly pain. I listened. I looked at his belly. No guarding, no rebound tenderness = benign abdomen = no scary belly. His vital signs? Normal. We talked about and it thought maybe it was just one of the kidney stones they saw passing. A few hours later, the intern and I get a call from the oncologist asking us to get some imaging because they're worried about this belly pain. I thought, "Really? His belly was so benign this morning."
We go to check on him. We walk into the room and he's sitting on the edge of his bed, hunched over, breathing fast. I felt my heart beat a little faster. "Mr. P? Are you alright?" I check his pulse. A little fast, but not that much faster than he has been. We check his belly. Still no guarding, still benign, but very tender. We meet the rest of the team to round and I ask that we see him first. The senior resident and attending check his belly. Still benign. The resident asks me what I want to do. I tell her I'm worried about this pain. Let's get an xray just to be safe.
I didn't think anything would be on that xray. I hoped not. It came back "free air under the diaphragm." But his belly is so benign. Could it be bowel in front of the liver? It can't be free air. Let's get a CT and call surgery. As he is getting his CT, surgery examines his belly. Benign. They're not going to operate. Until they see the CT confirming that xray. Free air.
With the team rounding, I didn't get to see him before they took him to surgery. I wish I did. I really wish I did. Just to tell him that he was in good hands. Just to tell him that we were going to take care of him. Just to tell him not to be scared. But I didn't get to see him.
I check the operative note before going to bed.
"Massive ileal perforation" "partial right hemicolectomy" "partial distal ileectomy" "bowel left in discontinuity" "taken to the ICU on ventilator"
Words I didn't want to read.
He was so happy to be finally getting his chemotherapy and to almost be leaving the hospital, and now he's sedated, intubated, with an open belly lying alone in an ICU bed.
Two words you never want to hear, specifically if it's followed by the phrase "under the diaphragm." You hear that, and it can only mean one thing... straight to the OR for an exploratory laparotomy where you get a vertical incision all the way down your belly to explore your abdomen for the cause of this "free air." Free air means that something has perforated or ruptured. Never good.
That patient I mentioned in my last post? My first patient on this rotation? The one I had to tell he had lymphoma? On of my FPs (favorite patient)? The one that was finally starting chemo and getting ready to be discharged? That one? His xray yesterday showed free air.
Every morning I walk into his room to ask him how he's feeling, and before I can even get the words out, he'll ask "How are you doin' this morning?" And he genuinely wants to know. Every evening when I check on him before I leave, he tells me to "you drive safe." Yesterday morning I walked into his room, and he told me about this belly pain. This belly pain that felt different from his normal belly pain. I listened. I looked at his belly. No guarding, no rebound tenderness = benign abdomen = no scary belly. His vital signs? Normal. We talked about and it thought maybe it was just one of the kidney stones they saw passing. A few hours later, the intern and I get a call from the oncologist asking us to get some imaging because they're worried about this belly pain. I thought, "Really? His belly was so benign this morning."
We go to check on him. We walk into the room and he's sitting on the edge of his bed, hunched over, breathing fast. I felt my heart beat a little faster. "Mr. P? Are you alright?" I check his pulse. A little fast, but not that much faster than he has been. We check his belly. Still no guarding, still benign, but very tender. We meet the rest of the team to round and I ask that we see him first. The senior resident and attending check his belly. Still benign. The resident asks me what I want to do. I tell her I'm worried about this pain. Let's get an xray just to be safe.
I didn't think anything would be on that xray. I hoped not. It came back "free air under the diaphragm." But his belly is so benign. Could it be bowel in front of the liver? It can't be free air. Let's get a CT and call surgery. As he is getting his CT, surgery examines his belly. Benign. They're not going to operate. Until they see the CT confirming that xray. Free air.
With the team rounding, I didn't get to see him before they took him to surgery. I wish I did. I really wish I did. Just to tell him that he was in good hands. Just to tell him that we were going to take care of him. Just to tell him not to be scared. But I didn't get to see him.
I check the operative note before going to bed.
"Massive ileal perforation" "partial right hemicolectomy" "partial distal ileectomy" "bowel left in discontinuity" "taken to the ICU on ventilator"
Words I didn't want to read.
He was so happy to be finally getting his chemotherapy and to almost be leaving the hospital, and now he's sedated, intubated, with an open belly lying alone in an ICU bed.
Thursday, January 24, 2013
"Please tell me the test ain't right"
Medicine can be tough. Really tough.
I've had to do things on this internal medicine rotation that I didn't want to do. Not because it's uncomfortable or because I thought I wasn't qualified, but because I didn't want to be the one to tell my patients the bad news. As paradoxical as it seems for a doctor, I want all my patients to come in healthy. I don't want to have anything to treat. I don't want to give them terrible diagnoses that we can only "manage" and MAYBE "cure."
My FIRST patient that I saw on this rotation had some suspicious lymph nodes in his belly. We did a biopsy, and I was the one to tell him the news...he had lymphoma.
That was tough, but not as tough as today.
I first saw her a few days ago. On getting her story and presenting the case, it seemed pretty straightforward. 56 year old female, shortness of breath, swelling in the legs, crackles and S3 heart sound on exam, all led to the diagnosis of heart failure. Heart failure is one of the most common conditions you see in the hospital. Straightforward, except not in this case. They were all little things. These little things that didn't quite add up. A chest xray that didn't look quite right. A strange bacteria causing a UTI. An anemia that wasn't fully explained by a folate deficiency. A gamma gap. A patient that seemed just a little too thin. My attending said, "Why don't we get an HIV test on her?"
She didn't seem to have many risk factors. Just a sweet 56yo women who didn't drink, smoke, use drugs and was just trying to raise her children and grandchildren right. Not currently sexually active but always used condoms. "Always?" I asked. "Always."
I was the one who went in and got her consent. My first time asking a patient's consent for an HIV test. I was nervous, and probably made it seem more serious than it was. I sat down beside her and told her that we would like to get an HIV test "to make sure that it wasn't part of what was causing her symptoms" and that "most people in the hospital get it" and "it's good to know your status." She responded like I had given her a heart attack by just mentioning the word "HIV." My attending went back with me later to explain how everyone should get an HIV test as it is recommended by the CDC. At that point, my patient was much calmer, saying, with a smile, that I had just scared her because I seemed so serious. At the time, I thought it was a good lesson about asking for HIV testing consent. Don't act like it's the end of the world, discuss the CDC recommendations, etc...
The HIV test was taking longer than expected to come back. "Maybe they didn't process it because of the holiday weekend," we thought, we hoped. When an HIV test takes longer to come back it generally means it was positive on the initial test and the extra time is because they are doing a confirmatory test (a Western Blot).
I called the lab today, she said she would call me back. I returned her call as soon as I felt my pager buzzing. "That patient you were asking about? They're doing the western blot." My heart sank. I felt a lump in my throat. My first thought was "please let the western blot be negative." Later that afternoon, I was telling my attending about the western blot and the phone rang. It was the lab. The test was positive.
We went in to tell her together. Closed the door behind us. Pulled the curtain dividing her and her roommate We sat down on the bed. My attending says "We have something to tell you. The HIV test came back. It was positive." My patient balled her hands into fists and threw her arms over her face. A look of shock came over her. Tears streamed down her cheeks. She kept repeating over and over, pleading with us "Please tell me the test ain't right?" I so wished that is what I could have told her. I wanted to tell her more than anything that the test wasn't right. She was fine. She didn't have HIV. She could go back to her normal life taking care of those grandbabies she loved so much not worrying about the word HIV ever again. But I couldn't tell her that. Yes, HIV isn't the disease it used to be. Yes, it's no longer a death sentence. Yes, it's treatable. Yes, you can live longer. Yes, the stigma is less, BUT the stigma is still there. All these things don't make hearing you are HIV positive any easier. I sat there with her for over an hour, just holding her hand and telling her all these reassuring things that didn't even reassure me. Before I left, I hugged her as tight as I could, somehow trying to make it better.
Her life is forever changed, and I'm part of the team that changed it. Not for the good. There is a silver lining. Finding out now means she is starting treatment earlier. She has a better chance. But right now, it's hard to see that silver lining. Right now it just feels very dark.
I've had to do things on this internal medicine rotation that I didn't want to do. Not because it's uncomfortable or because I thought I wasn't qualified, but because I didn't want to be the one to tell my patients the bad news. As paradoxical as it seems for a doctor, I want all my patients to come in healthy. I don't want to have anything to treat. I don't want to give them terrible diagnoses that we can only "manage" and MAYBE "cure."
My FIRST patient that I saw on this rotation had some suspicious lymph nodes in his belly. We did a biopsy, and I was the one to tell him the news...he had lymphoma.
That was tough, but not as tough as today.
I first saw her a few days ago. On getting her story and presenting the case, it seemed pretty straightforward. 56 year old female, shortness of breath, swelling in the legs, crackles and S3 heart sound on exam, all led to the diagnosis of heart failure. Heart failure is one of the most common conditions you see in the hospital. Straightforward, except not in this case. They were all little things. These little things that didn't quite add up. A chest xray that didn't look quite right. A strange bacteria causing a UTI. An anemia that wasn't fully explained by a folate deficiency. A gamma gap. A patient that seemed just a little too thin. My attending said, "Why don't we get an HIV test on her?"
She didn't seem to have many risk factors. Just a sweet 56yo women who didn't drink, smoke, use drugs and was just trying to raise her children and grandchildren right. Not currently sexually active but always used condoms. "Always?" I asked. "Always."
I was the one who went in and got her consent. My first time asking a patient's consent for an HIV test. I was nervous, and probably made it seem more serious than it was. I sat down beside her and told her that we would like to get an HIV test "to make sure that it wasn't part of what was causing her symptoms" and that "most people in the hospital get it" and "it's good to know your status." She responded like I had given her a heart attack by just mentioning the word "HIV." My attending went back with me later to explain how everyone should get an HIV test as it is recommended by the CDC. At that point, my patient was much calmer, saying, with a smile, that I had just scared her because I seemed so serious. At the time, I thought it was a good lesson about asking for HIV testing consent. Don't act like it's the end of the world, discuss the CDC recommendations, etc...
The HIV test was taking longer than expected to come back. "Maybe they didn't process it because of the holiday weekend," we thought, we hoped. When an HIV test takes longer to come back it generally means it was positive on the initial test and the extra time is because they are doing a confirmatory test (a Western Blot).
I called the lab today, she said she would call me back. I returned her call as soon as I felt my pager buzzing. "That patient you were asking about? They're doing the western blot." My heart sank. I felt a lump in my throat. My first thought was "please let the western blot be negative." Later that afternoon, I was telling my attending about the western blot and the phone rang. It was the lab. The test was positive.
We went in to tell her together. Closed the door behind us. Pulled the curtain dividing her and her roommate We sat down on the bed. My attending says "We have something to tell you. The HIV test came back. It was positive." My patient balled her hands into fists and threw her arms over her face. A look of shock came over her. Tears streamed down her cheeks. She kept repeating over and over, pleading with us "Please tell me the test ain't right?" I so wished that is what I could have told her. I wanted to tell her more than anything that the test wasn't right. She was fine. She didn't have HIV. She could go back to her normal life taking care of those grandbabies she loved so much not worrying about the word HIV ever again. But I couldn't tell her that. Yes, HIV isn't the disease it used to be. Yes, it's no longer a death sentence. Yes, it's treatable. Yes, you can live longer. Yes, the stigma is less, BUT the stigma is still there. All these things don't make hearing you are HIV positive any easier. I sat there with her for over an hour, just holding her hand and telling her all these reassuring things that didn't even reassure me. Before I left, I hugged her as tight as I could, somehow trying to make it better.
Her life is forever changed, and I'm part of the team that changed it. Not for the good. There is a silver lining. Finding out now means she is starting treatment earlier. She has a better chance. But right now, it's hard to see that silver lining. Right now it just feels very dark.
Wednesday, December 19, 2012
Tuesday, December 4, 2012
"You just need a man to figure it out"
Setting: the female fellow and male attending are working to place a new dialysis graft in the patient's arm.
They are trying to figure out how to work with a different tunneler when the attending says, "You just need a man to figure it out."
At another point in the surgery when the fellow was questioning the position and number of the vessel clamps, he again responded, "You just need a man to figure it out."
In both these instances, the fellow half-heartedly laughed in response. Was the attending saying this in a joking manner? Yes. Does that make it ok? I say no.
Just some food for thought.
They are trying to figure out how to work with a different tunneler when the attending says, "You just need a man to figure it out."
At another point in the surgery when the fellow was questioning the position and number of the vessel clamps, he again responded, "You just need a man to figure it out."
In both these instances, the fellow half-heartedly laughed in response. Was the attending saying this in a joking manner? Yes. Does that make it ok? I say no.
Just some food for thought.
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