A nurse practitioner talks about a resident and a complicated patient

I worked with a patient, 84 or 86 years old, with some dementia but still living alone despite multiple medical problems.  She had chronic renal insufficiency, hypertension, diabetes, gout, and also was on anticoagulants. She couldn’t keep her meds straight.  This patient needed a team, and I had to put the team together.  The PCP became very involved.  She wanted to see the patient frequently and not expect me to do all the hard work. I also had to see the patient frequently, and in-between visits I would report to the resident or the attending. I also ended up seeing the patient at home because it was difficult for the patient to come in.  The resident then asked me if she could accompany me on a home visit and I thought sure, between the two of us it should be quick visit.

Not so. Not when the resident spent over an hour looking through photo albums. At first I think the patient was really shocked that the doctor was at all interested in these things.  The patient had been to nursing school and had pictures of her graduation on the wall.  The physician asked questions about her school, nursing jobs, her marriage, her family life and what brought her to Charlottesville.  This patient discovered her doctor really cared.  The doctor wanted to know about the patient’s day-”What do you do when you wake up, and let’s go to the kitchen and show me what’s in your fridge”-but it wasn’t threatening in any way.  She kept telling the patient, “I just what to know what makes your day go by and what makes you tick.” 

Afterwards I told the doctor, “If you weren’t a doctor you would make a great nurse practitioner.” 

I think we kept her out of the hospital. I know this seems like enabling but the patient lives on my way into work so I pick her up every once in awhile and take her to see her nephrologist because she had so much trouble just figuring out how to get through the medical system. Unfortunately she did end up in a nursing home.  Her dementia ended up so bad that she was found down a couple of times and ended up taking too much of her medication even though it was in a med box. 

The patient relationship for me was very rewarding, the patient was just absolutely lovely and she appreciated every time I came over.  She really, really didn’t want to be in a nursing home, so that is why all this work went into this. She loved her little apartment and her neighbors. I would love to be able to dedicate this much time to all my patients who need me, but I know that is not really appropriate.  This was kind of the ultimate nurse practitioner experience, the right patient, the right resident, involved attendings, and as a team the opportunity to prevent a lot of bad things.

Recently I looked up a complicated patient, thinking, “Why isn’t the resident asking me for help? This patient has so many demands, has home health and has maybe 8 different real medical problems or issues all the time.”  It turns out this doctor sees him every other week, and I think, “Oh my gosh, how do they do that?”

 An attending talks about caring for a difficult patient

Mrs. M is 56 year old “problem patient.”  She is on chronic anxiolytics for anxiety and panic attacks, and she always calls early needing more than prescribed, either saying she has had more stress, or they were stolen, or fell in the toilet, etc.  Despite always needing more clonazepam, she rarely keeps her regular appointments with the resident who is her PCP.  About a month ago she paged him, saying she was having difficulty swallowing, especially solid food.  He tried to get her to come in for an appointment, but she resisted.  He agreed to order a barium swallow and then to see her, but the initial appointment for the test was scheduled in almost a month.  When she called back in a week saying she was having more difficulty swallowing, the resident called radiology and was able to move the test up. 

On the day of the test, the resident was called by the radiologist who said the patient had a 7 cm mass constricting her esophagus suggestive of esophageal cancer.  They recommended a CT scan.  The resident called the patient to say she needed another test, and several days later the CT confirmed a mass in the esophagus, but no obvious local invasion or adenopathy.  An EGD was then quickly obtained, and biopsy of the mass did show she had an squamous cell carcinoma.  Through all of this, the patient still hadn’t been seen at UMA, but she was calling the resident and his firm nurse at least daily.  After the procedure, he had no clinic time to go over the diagnosis with the patient, so she was scheduled to see me instead.  On the morning of her appointment, she called once again to cancel, saying she had no transportation, but she wanted to know the results of the biopsy.

The resident, the firm nurse and I discussed this, and decided it would be best for the resident to call her and give her the results over the phone.  She had already had breast cancer successfully treated with surgery so she knew something about what to expect.  When he called her, he said she took the news well, and indicated she had support at home and wasn’t feeling depressed.  She said she would keep an appointment with me in two days to discuss her diagnosis in more detail.  In the interim, her firm nurse called the surgeon’s office to find out what other tests he would want, and arranged an appointment in 6 days.  Before that, she scheduled both the PET scan and endoscopic ultrasound he wanted. 

When I saw her two days later, she was quite calm.  She said her family was taking it very hard, and she needed to be strong for them.  She was very thankful that she could get the other tests she needed and see the surgeon within a few days.  She was still having trouble eating solids, but was eating pudding and five or six cans of Ensure a day.  She didn’t need more anxiety medicine or anything for pain. 

She had her tests and saw the surgeon, who recommended chemotherapy and radiation followed by surgery as her cancer appeared localized.  Before the diagnosis, she called one of her providers at least daily.  After the diagnosis, no one heard from her.  When we realized she wasn’t calling, the firm nurse called her.  She e-mailed us the outcome. The patient said she was ok.  Her family had bought her a new dress and her sister had taken her to get her fingernails and toenails done.  The nurse told her not to milk this for too much.  They both had a good laugh.

This episode struck me because of the way that the resident, the firm nurse and I were able to work together in a tough situation, with a patient with a potentially fatal condition who wasn’t making it easy for us.  The resident took the lead when he could, I was able to help out, and the firm nurse made sure everything got done and held it all together.  The patient wound up getting a barium swallow, CT scan, EGD, EUS a PET scan and saw a surgeon in two weeks, all as an outpatient.  That’s quite remarkable in our system, and is the way things are supposed to work, but it wouldn’t have happened without us working as a team, and especially without the firm nurse knowing how to get things done.  The resident did a good job of directing things and being willing to give the diagnosis under less than ideal circumstances, and he was also willing to appropriately let others help him.  My role was mostly as a facilitator, supporting the resident and the firm nurse and filling in when I needed to.  The biggest surprise for all of us was the patient, who has demonstrated amazing resilience and courage.  She still has a very difficult and uncertain future ahead, but I feel much better about our ability to provide her excellent care, and her ability to participate positively in her own care, than I did a month ago.

 A medicine attending writes about a patient from Cincinnati & a resident from urology

I don’t ward attend as much as I’d like (hard to leave my clinic unattended), but over the Christmas holiday clinic slows down enough and the ward attending schedule is desperate enough, that I often cover a general medicine service. 

Last year we had a patient transferred from West Virginia in respiratory failure.  He was from Cincinnati and did not know a soul in Charlottesville.  After a few days in the MICU he came to us on antibiotics for community acquired pneumonia, on anticoagulants for a new pulmonary embolism, on high flow oxygen, and with a right renal mass that looked bad.  Mostly he complained he was hungry.  We decided he needed a vena cava filter, a chest tube for a large para-pneumonic effusion, and a nephrectomy.  He got the filter, refused the chest tube, refused surgery because it couldn’t be scheduled for weeks, and by the way, he lived in Cincinnati. 

We decided to drain his chest ourselves.  In my time, in the days of the giants, medical residents did the thoracentesis at the bedside, using percussion and auscultation to localize the fluid.  Fluid is dull to percussion, but so is the liver, so is the spleen, and so we tried to give the hemi-diaphragm plenty of space.  And there we were, a 14 gauge catheter in the patient’s chest, and 100 cc’s at a time we proceeded to remove two liters of sero-sanguinous fluid.  I was in no rush.  The patient was not going anywhere. The resident was a captive audience.  He and I took turns at the syringe, and the three of us had time to talk.  I was curious why the patient was in West Virginia. 

Turns out a woman was involved.  Turns out alcohol was involved.  Turns out poor judgment was involved.  We are all human, and there are many ways to end up with a large pleural effusion.  Discharge planning should begin the day of admission.  The patient’s plan was to drive to Cincinnati and get himself admitted for nephrectomy through an ER.  We reviewed his plan.  I reminded the patient that his car was in Cincinnati, that he shouldn’t be driving, that he might need some oxygen for the trip, and that his wife, given the circumstance of his absence, was not inclined to either take him home or drive him home.  Maybe his sister would fetch him.  By that point we had surpassed our pleural fluid goal.  The patient tolerated the procedure well, but complained he was hungry.

The urology resident spoke to her attending, and the attending had a colleague in Cincinnati.  Suddenly we had a plan.  The next day the patient’s room air O2 sats were above 90%.  I encouraged him to get out of bed and start exploring the grounds of his new home, UVA Hospital.  I gave him some money to go the gift shop to buy a candy bar.  On rounds the next morning he had six dollar’s worth of candy on his bedside table-my dollar plus the resident’s five.  His sister was there too, looking like a big sister.

The patient returned to Cincinnati.  I returned to clinic.  The resident went into his subspecialty.  This Christmas I am on the wards again.

 A third year student talks about a patient and his family

I admitted a man who thought that he was coming in for a simple infectious disease and only a few days later found out that he actually had metastatic melanoma and wasn’t going to make it more than a few months, if that long.  It was quite the surprise for the patient and his family and quite a surprise for the team based on his presentation.  During his hospitalization, I was able to really get to know the family.  Each day, the wife would bring old pictures of the family to show me and the son would give me a hug as he walked out of the room.

One night, we had a lot of trouble with a cross-cover resident not taking care of pain for this patient.  It was nice to be able to quickly assure the family that that wasn’t ever going to be a problem again.

One evening, I was the last member of my team in the hospital, and I felt the need to check on this patient before I left because I knew that this might be the day he was going to pass away.  I arrived to find him dead.  He had apparently passed away about 2 minutes before I walked up the stairs.  I spent some time with his family in a conference room and then noticed that the nursing staff were preparing his body for the family to view.  I was able to go in and help pull out all the tubes and IV’s and do everything to get him ready, and then it was noted that the body was supposed to be donated to science.  I was totally humbled by this, and the family was overwhelmed, but it was just more evidence of how neat of a guy this was.

 A student writes about a home visit

As a quadriplegic, Ms. W’s world for the past seven years has been a twin bed in the center of a small dark room.  Her husband left a long time ago, and the children are grown.  She spends her day with the TV blaring. At first, I thought her situation seemed lonely and isolating.  Then she began to speak.  She talked in a matter-of-fact way about her medical concerns.  She led the conversation at her own pace, asking for clarification when she didn’t understand, and explaining what she thought might be wrong.  Clearly, Ms. W was not helpless or powerless.  She was a grown woman who was in control of her life despite her reliance on others for certain things.  There was not a hint of hopelessness or resignation in her voice.  She was not depressed about her paralysis at all, just practical about the issues that she faced.  As we talked, her playful comments and jokes proved that her wit and spirit were intact.  I left the apartment without feeling sorry for her.  She has adjusted to a life most of us can’t imagine spending one day in.  She is a survivor.

 A third year student talks about a family meeting for a patient who is terminally ill

His son and wife were there as well as another son and his wife and four other family members.  They hadn’t really come to terms with the fact that their father was dying, the oncologist hadn’t really given them information about the patient’s diagnosis, and they were really uncertain about how sick he was.  We told them it would be a good time to let other family members know, and then we talked about Hospice….

The amazing part was that the questions were directed at me.  It was my most major experience in being the doctor and taking ownership of my patient.  I was the member of the team who was most in communication with him and his family.  It just turned out that way, and the resident allowed me to have that space, and I felt comfortable taking it.  The resident’s recognition of it afterwards was key.  He gave me credit and told me that I did a fantastic job.  That day, I felt a tremendous amount of responsibility.

Our team really, really gelled.  I was treated as an equal member instead of just being an observer.  Medical students, if given the opportunity and encouragement, can have an integral role.  On the wards, the medical elements may be less important than the feelings, and that is where medical students can contribute.  There is always an emphasis on diagnostic tests and labs and differential diagnoses, which is all extremely important; but, there is less of an emphasis on the doctor-patient relationship and on how to communicate with patients and their families.  A patient’s not just a person lying in the bed, and I think that’s really important to always remember.

 A third year student talks about a great attending

As a 3rd year student, you are always scared of getting pimped, being asked questions and not knowing the answer.  When I was in the intensive care unit, I had a great attending who would get the whole team together and then ask every member of the team questions.  He would go around in a circle so that every single person had to answer and by the time you got to the end nobody remembered who was right or wrong.  Then, he would tell the answer without acknowledging that anybody was right or wrong.  When I didn’t know the answer, I would sometimes try to think of something that would help people laugh because you tend to get a little bit downtrodden in the intensive care unit when a lot of patients don’t do very well.  When you are working with a group of people that are happy to be there and are very supportive of each other and can laugh together, it makes the whole thing worthwhile.  This attending made me feel smart.  Even when I said the wrong answer, he made me feel like I had contributed.  It didn’t even feel like work…