My Chronic Disease Patient
Plan:
- My first day on service- meeting the resident, my excitement, nervousness
- Mr. O - his PMHx, his current situation, his course of hospital care
- Dr. S comment
- My feelings about it
On the first day of my internal medicine service, about 5 weeks ago now, I was excited, but nervous. I had pretty much ruled out the other rotations as possibilities for careers based on one reason or another. This was it. If I didn't like medicine, I would have to go back and decide what I liked best. I walked in with a positive attitude and was paired with a partner who was extremely bright. Instead of worrying about how he would make me look bad with his ridiculous amount of knowledge, I thought about how I could learn to study from him and maybe how to process and grasp material from him. It was going to be a GREAT rotation even if i hated medicine. We met up with our residents and he quickly looked down the list of patients and assigned me to Mr. O, who was actually sitting in a stretcher right in front of me waiting for an ultrasound.
He looked terrible. At 62, he looked more like 92. When I read about his history, I could understand why. He had suffered a stroke, epidural abscess, sacral decub ulcer, congestive heart failure, diabetes mellitus, to name just a few. His major problem was a persistent bacteremia carrying very resistant bugs to antibiotics. On top of that, he couldn't swallow food anymore due to a risk of aspiration and was told he was not allowed to eat anymore and would be receiving food through a stomach tube for the rest of his life.
I followed him over 5 weeks. He was worse at times, better at others. He has trouble speaking and at times I could barely make anything out. I would tell him to nod when I asked questions. There was a point when we realized the antibiotics might cause toxicities in his blood and eventually put him into renal failure and kill him. Our attending that week commented that she wasn't sure how long he would live if the bacteria persisted like this. There was also another point where the bacteria cleared and he was practically on a stretcher ready to be wheeling into a nursing home. Some metabolic disturbance that kept him a few more days to correct and eventually put him back into a bacteremic state. We could never pinpoint the source and just treated according to what the cultures were sensitive for.
This week, we met with our attending from the beginning of the rotation. She asked us how our patients were and I commented that Mr. O might actually be leaving in the near future. She looked at me and said, "Oh, he's still alive?" and then continued with her evaluation of our performance.
For some reason, it upset me that Mr. O was going to die from this bacteremia. I was reluctant to believe that antibiotics were not going to take care of this, especially since they were very aggressive toxic medications. I realized it was a lose-lose situation. Even if the bacteremia didnt' kill him, the antibiotics would make his kidneys worse and he might get kidney failure- another problem bringing him closer to the brink of death. I started looking forward to the days he would feel well enough to make out a "pretty good" out of his mouth and loathing the days when he would just look at me with his extremely sad, resigned eyes. At 62 Mr. O was never going to walk, eat, or get out of bed again. But maybe he would one day sit up, read and at least communicate with his brother when he came to visit at the nursing home. I have to at least hope for that.
- My first day on service- meeting the resident, my excitement, nervousness
- Mr. O - his PMHx, his current situation, his course of hospital care
- Dr. S comment
- My feelings about it
On the first day of my internal medicine service, about 5 weeks ago now, I was excited, but nervous. I had pretty much ruled out the other rotations as possibilities for careers based on one reason or another. This was it. If I didn't like medicine, I would have to go back and decide what I liked best. I walked in with a positive attitude and was paired with a partner who was extremely bright. Instead of worrying about how he would make me look bad with his ridiculous amount of knowledge, I thought about how I could learn to study from him and maybe how to process and grasp material from him. It was going to be a GREAT rotation even if i hated medicine. We met up with our residents and he quickly looked down the list of patients and assigned me to Mr. O, who was actually sitting in a stretcher right in front of me waiting for an ultrasound.
He looked terrible. At 62, he looked more like 92. When I read about his history, I could understand why. He had suffered a stroke, epidural abscess, sacral decub ulcer, congestive heart failure, diabetes mellitus, to name just a few. His major problem was a persistent bacteremia carrying very resistant bugs to antibiotics. On top of that, he couldn't swallow food anymore due to a risk of aspiration and was told he was not allowed to eat anymore and would be receiving food through a stomach tube for the rest of his life.
I followed him over 5 weeks. He was worse at times, better at others. He has trouble speaking and at times I could barely make anything out. I would tell him to nod when I asked questions. There was a point when we realized the antibiotics might cause toxicities in his blood and eventually put him into renal failure and kill him. Our attending that week commented that she wasn't sure how long he would live if the bacteria persisted like this. There was also another point where the bacteria cleared and he was practically on a stretcher ready to be wheeling into a nursing home. Some metabolic disturbance that kept him a few more days to correct and eventually put him back into a bacteremic state. We could never pinpoint the source and just treated according to what the cultures were sensitive for.
This week, we met with our attending from the beginning of the rotation. She asked us how our patients were and I commented that Mr. O might actually be leaving in the near future. She looked at me and said, "Oh, he's still alive?" and then continued with her evaluation of our performance.
For some reason, it upset me that Mr. O was going to die from this bacteremia. I was reluctant to believe that antibiotics were not going to take care of this, especially since they were very aggressive toxic medications. I realized it was a lose-lose situation. Even if the bacteremia didnt' kill him, the antibiotics would make his kidneys worse and he might get kidney failure- another problem bringing him closer to the brink of death. I started looking forward to the days he would feel well enough to make out a "pretty good" out of his mouth and loathing the days when he would just look at me with his extremely sad, resigned eyes. At 62 Mr. O was never going to walk, eat, or get out of bed again. But maybe he would one day sit up, read and at least communicate with his brother when he came to visit at the nursing home. I have to at least hope for that.