A resident talks about a young patient

As residents we get very busy and stressed out and sometimes forget that we can make a difference in somebody’s life.  I was helping to take care of a 14-year-old girl with a recent diagnosis of AML.  It felt like every time I walked into this girl’s room she was upset with me.  I’d say something stupid like, “Oh, is your hair starting to fall out?” and she’d cry. Or I’d ask, “Is that rash itchy?” and she said, “Of course it is, are you stupid?”

She always wanted to know when one of the attendings would be in, and why did I have to examine her in addition to Dr. W.  or Dr. D.?  She really didn’t want to have anything to do with me, but every day I came in and examined her and got to know her a little bit.  One morning, just as I about to pre-round, I heard an overhead page for the on-call resident to a room number that was hers.  A bunch of people started to run, but I beat them there.

She was sitting up in bed, her sats were down in the low 80’s, her blood pressure was low, her heart rate was up, and she looked at me with the most grave face I have ever seen.  Platelets were infusing.  We stopped the platelets, gave saline, watched her vitals, and over the course of about 10 minutes she was looking much better.

I said, “Okay, I’m going to go out and call the blood bank and call Dr. D. so that she can come in and make sure everything is okay,” but the patient reached out her hand, touched me on the elbow, and said, “Don’t go.” And so I didn’t.  Maybe it was just seeing my face every day, there was something comforting about my presence in the room when she was scared, when she thought she was dying.  After the first few minutes I had no medical purpose for being in the room, but she wanted me there.  I mean, how moving is that?…that our job lets us affect somebody that way?

Tags: Female, Patient care, resedent.

 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.

Tags: Faculty, Patient care.

 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.

Tags: Patient care, Student, team.

 A student writes about an extracurricular activity

During first year and the summer after first year, I worked in the Childhood Obesity Clinic.  It was a fitness clinic and nutrition clinic for overweight kids in the community.  When they came, the kids would receive education and also a chance to exercise in an effort to combat their obesity and the self-esteem and other social issues that came with it.  The nutrition component was very interesting.  You would see the kids knowing the correct answers to all of the questions we asked: how many calories are in this, how much fat is in this, is fat better than carbs, are carbs better than protein, which vitamins are in this food, etc.  However, it really seemed like a game to them.  They would go to McDonald’s on the way to the game, then play the game and answer all of our nutrition questions, and then leave and go back to McDonald’s on the way home.  It taught me that it is not enough to give patients information and then challenge them to learn it and to answer questions correctly.  If you expect to help people change their unhealthy habits, you have to make sure they really hear what you are saying, understand the significance, and buy into the idea.

In addition to this valuable lesson, I also learned tremendously powerful lessons by playing games with the children after the nutrition sessions.  One day, we played football with two mixed teams of medical students and clinic participants.  There were several very bright, very motivated medical students who wanted to help these kids and several very, very overweight children.  Watching the game, you could see that these kids had never had a chance to really interact in a physical way with their peers.  It seemed that they wanted the opportunity but had not figured out how to obtain it yet. 

I remember very vividly one particular play in which I threw a touchdown pass to one of the little boys.  He was a 12-year old kid who was probably about 4′ 5″ and extremely obese, and it was remarkable to watch his eyes light up as he caught the ball, turned, and ran down the field with medical students following after him.  They were not necessarily trying to outrun him, but they gave him the chance to compete as he ran all the way down the field.  When he scored the touchdown, he did a little victory dance and really celebrated.  It was wonderful to see how much he benefited from what he was able to do and feel.  The physical experience during our games was probably more valuable to these kids than any of the nutrition instruction.  I am happy to say that I think my classmates and I have continued to remember this lesson, especially during our clinical years.  There is much more interacting than lecturing when we are learning from each other, and this is also true in our patient relationships.  I think it’s really a wonderful thing to see.

Tags: obesity, Patient care, Pediatrics, Student.

A student, after a home visit, writes about the patient and his website

I read through Professor N’s notes on the eye, and they were beautiful. [Retired, and slowly dying of pancreatic cancer, Professor N used to teach a course on the physics of the body.]  It was evident that he exerted a great deal of love, care, and attention to detail in preparing these notes for his class.  Even for a non-physics student, his notes were easy to read and well organized.  He included a number of interesting factoids and fascinating optic phenomena that helped to make the text anything but dry.  My favorite component was his diagram illustrating the blind spot.  When we went over this concept in class, I was skeptical.  I would sequentially cover each eye, unconvinced that in isolation either eye was lacking in its perception of part of its respective visual field.  However, after testing my eyes on Dr. N’s blind spot diagram, I was finally sold.  Furthermore, the figures he had selected were colorful and well laid out and, combined with a simple yet elegant font, formed a wonderfully appealing visual aesthetic that required little education other than an appreciation for beauty.  As I read through the lecture, I felt a strong conviction that it was prepared by a person who loved life, someone who had a true passion for learning and teaching.

Tags: Patient care, Student.

 A student writes about a cardiac surgery patient

It was literally the third week of my third year of medical school, and I was on the Cardiac Surgery service.  I finally had my very first patient that I could consider my own.  I was there when he arrived, and I was able to complete his History and Physical.  He was going to have some imaging studies and then a CABG procedure.  I met both he and his wife as I learned about his medications, allergies, past medical conditions, and social history.  The two were an extremely friendly couple. 

The next morning, I was able to scrub in for his operation.  I even held his heart in my hands while the surgeons manipulated his vessels.  I distinctly remember his lungs being perfectly pink, as he had never smoked a day in his life.  I completed his post-op check and rounded on him every morning after his procedure while he remained in the hospital.  I enjoyed meeting him in the hallway during the day and continuing to encourage him and congratulate him on his post-operative progress.

On the Friday after his surgery, I went to say goodbye to the patient and his wife since I knew that they would be discharged over the weekend while I was gone.  I thanked him for letting me be an active part of his care time and allowing me to learn from him.  Both he and his wife said that they were lucky to have had me on their team because I would make a great doctor one day.  His wife even said that I should definitely go into Family Medicine so that I could be her doctor when I finished my training.

Tags: family medicine, Patient care, Student, training.

A pediatrician writes about a remarkable resident and family-centered care

The KCRC prides itself on providing family-centered care from the housekeepers to the pediatric attendings. Families participate in all the interdisciplinary team meetings and share in making clinical decisions. Families serve on the KCRC Advisory Board and search committees. And the KCRC values each patient and his or her ability to make functional and developmental progress at their own rate. Insurance payment for inpatient head injury rehabilitation is based completely on the established metrics of cognitive and physical recovery from trauma or disease. The KCRC staff champion all the children, infant to adolescent, especially the most disabled. Well, usually, that is….

This six-month old baby, a former 28-week premie, was making no progress and had made no changes since she had been transferred from the NICU three months earlier. Not even a reflexive suck or doll’s eye opening. No change in her vital signs. Not even diurnal variation in her body temperature which remained rock solid at 94 degrees even with swaddling. No response to cuddling in the rocking chair or lullabies from the nurses. One of the parents called the nurses’ station regularly every afternoon to inquire about her progress, but they had long stopped visiting. There were no wrist rattles or pretty pink onesies hanging on her crib.

The family wasn’t ready to take her home with their other three healthy children and they weren’t agreeable to her transfer to a nursing home. The doctors, the nurses, the social workers, the finance officers, the Clinical Ethics Team, their family doc and the local public health nurse had all tried unsuccessfully to reason with the family. The lullabies gradually stopped, the pediatric team skipped that crib on morning rounds and the chart notes became more about the responsibilities of the institution than the rights of the patient. A Medicaid nursing home bed was identified in Richmond and transportation for a safe transfer was arranged with one of the KCRC nurses in company. A final summit with the family was planned on a Saturday morning……who on the team had the best rapport or the most power? Who would sit in the family lounge over coffee and deliver the absolutely final eviction notice? There were no volunteers.

I was the inpatient attending outlining the tasks for the weekend, including the parent conference scheduled on Saturday morning. I had assumed that I would end up doing the dreaded duty. But no, my intern, Dr. H., suggested that she thought she would like to try…she had answered the phone yesterday at the nurses’ station when the mother called in and she had given the 24-hour update to the mother. It felt like a connection to Dr. H. I acquiesced but felt a little guilty in doing so, And so it was that I dawdled in the house staff office, waiting to be called for the inevitable rescue of my first-year resident. And here she was at my elbow…

“We need a priest….right now,” she said to me.

“What for….? I can probably get the hospital chaplain on call to come in,” I replied, more than a little nonplused by the urgency of the conversation and the unexpected call for clergy on a Saturday morning.

“No, no!” she insisted. “We need an honest-to-God Catholic priest…right now, before they change their minds.”

“Okay, okay, but what’s happening about the transfer? Shall I call the ambulance service?” I pressed. “What’s going on in there? Shall I come in with you?”

She shook her head and rushed to say: “No, no.” Her words erupted: “I introduced myself and sat down. And right away …when I asked about the baby’s first name… you know how you’re always supposed to call the baby by her name when you deliver bad news? I think you taught me that even… the mother started sobbing and I got her a Kleenex, you know, I had the box right next to me just like I was supposed to….well, I put my arm around the mother’s shoulders and patted away and she just kept sobbing…then the father explained that their baby didn’t have a name, probably not even a soul …because she had been too sick in the NICU to be baptized, and then the chaplain was a Unitarian and now she would end up in limbo if she went out in the winter air to get to the ambulance… and then out on the highway to Richmond there might be an accident ….she’s so little and the traffic is so fast on route 64.” She took a quick breath and kept going. ” SO, I need a Catholic priest right now… and the baby’s name will be Mary Beth, and then the baptized baby Mary Beth can go live at the nursing home in Richmond… then, if anything happens to her, she will go straight, absolutely straight without questions asked, to heaven… and then, the parents can go back to church again, to Saturday night confession again and take communion at Sunday mass with all their neighbors…. It’s okay, honest, we just need a Catholic priest right now.”

And so I called St. Thomas right around the corner from the KCRC. We had a priest in no time. No one seemed too concerned that his Saturday morning attire featured sandals, jeans and a clerical collar under a sweat shirt. Dr. H. and the nurse stood in as godmothers. The baby was duly baptized “Mary Beth in the name of the Father and the Son and the Holy Ghost. ”

The Pediatric faculty and residents at Monday’s morning report were stunned when Dr. H. reported the successful transfer of Mary Beth, the hugs from these most difficult parents and the general disbelief of the KCRC staff. Dr. H. was recognized at the formal Rotunda dinner the following June as the most family-centered resident in Pediatrics. And the staff and faculty at the KCRC reflected once again that family-centered care is redefined by each family and not by the staff.. Isn’t it grand to have all those idealistic students and residents around to teach when we wise ones lose our way?

Tags: Difficult patient, Faculty, GME, Patient care, Pediatrics, Teaching.