On Another's Sorrow

Can I see a falling tear,
And not feel my sorrow's share?

As the intern year has gone on, compassion has been harder to feel, and later, even to fake. Patients mean work, and when your work is this draining and frustrating, the real people behind the mountains of paperwork become frustrating.

All this was put into perspective last night. I was on call, shambling back and forth with as much celerity as I could muster at 2am, when the overhead intercom burst forth with "Attention in the hospital, code blue, labor and delivery, room 9."

Codes are never easy to deal with, but with most of the geriatric medicine codes I've seen, there is a sense of resignation despite the furious efforts. After all, there are very few 85 year olds who will make anything like a full recovery after two minutes of CPR. A code on L&D is a different matter entirely.

When I arrived, the anesthesia and surgery teams who work on the same floor had unsurprisingly beaten my two-floors-of-stairs-sprint to the scene. I stayed just long enough to get a general idea of what had happened from one of the residents, and then I turned to go back to my work. The patient had HELLP syndrome, a rare but not unheard of complication of pregnancy, and had coded shortly after a crash c-section.

Walking out through the waiting room, I ran into the woman's husband. He was scared, worried, and completely in the dark. His first question was "how is Susan?" His second was "what does code blue mean?" Realizing his need, I started talking to him, answering what questions I could, both as a physician and as someone who genuinely cared.

And that was the shock. I realized, despite the bitterness, despite the pain, despite everything that over the last few months has brought so many undesirable characteristics to the fore in my personality, I did care. I'm not sure anyone who hasn't gone through a similar situation can fully understand this. The point of it was, I really did care, I do care, and though I am saddened to know it took something so extreme to remind me of it, I am enheartened that I have been reminded.

He becomes a man of woe,
He doth feel the sorrow too.

Happy ending

A number of months ago I discharged a patient to a physical rehabilitation center. This is pretty common, and it seems especially so in internal medicine, where there is a large proportion of old patients with multiple problems complicated by poor physical condition.

Mr. Sigursson was not happy about going to this place though. I had tried to walk him around the ward, and he got short of breath just getting out of bed. He was too deconditioned to brush his teeth. But his wife had died six months before in a similar institution, and as he expressed at length to me: "I'm 93 years old, I've been an elder in my church, I've founded charitable organizations, I've done all the fishing I'll ever do, and now I've sold my house, my boat, and everything else that I used to do to live in an assisted living apartment. I'm done with life, why the hell do I need rehab?"

In short, he was ready to join his wife.

Honestly, I didn't know that rehab would do him any good. He was pretty sad, and he had great reasons for being so. He wasn't motivated to succeed with physical therapy, and as he said, he had little to look forward to once he got out. I always feel a little out of place, being 27 and telling people nearly four times my age that "there's a lot left to live for."

So it was with great pleasure, and not a little amusement, that I saw him at the grocery store today, pulling his walker out of the bed of his pickup truck without lowering the tailgate.

He was smiling.

Cross cover

Being on call overnight gives an intern a great idea how strong his fellow interns are. The weaker of my fellows will have signed out patients who lack pain PRN meds, have restraint orders that need to be signed, or a host of other administrative issues guaranteed to keep me awake.

It also demonstrates some of the odder quirks of humanity. I was paged by one of my favorite nurses a few nights ago "because one of the patients up here has a present for you." I tried cajoling the nature of the "present" out of her, but she insisted I come and see it for myself. She's one of the nurses I know fairly well, and more importantly I know she doesn't page me unless it is necessary, so I headed up four flights of stairs to see what was going on.

When I got there, the nurse dropped a small white object into my hand and told me the story. Mrs. Culloden, a pleasantly demented, frail lady in her 80s who is constantly threatening to leave AMA to go smoke, had become convinced that the vancomycin in her PICC line was "invading her body." Her logical response, rather than asking a nurse for help, was to take the plastic knife from her dinner tray and cut the port off her PICC line. So the vancomycin was on the bed, and the wanderingly apologetic Mrs. Culloden was one step further back on her cellulitis treatment. Clamp, wrap, and place on 1 to 1 monitoring. All in a day's work.

Seriously

I'd just like to say that I'm, well, I'm searching for the right word to describe my feelings towards a certain pain management doc. The one who told my patient, perhaps the most difficult patient I've ever had to deal with, the one with a fragile ego and chronic pain and a sense of entitlement and probably borderline personality disorder, the one I spent two weeks getting stabilized on a pain management regimen while an inpatient, told this patient that "methadone is a drug for heroin addicts." So now the patient is back, refusing the one drug that got him out of the hospital, and I guess I really want to transfer all of his pain to the idiot pain management physician.

Sigh.

Just another patient

I occasionally read other medical blogs, and the posts I usually enjoy are the ones with a gripping story. I've told a few myself. But there haven't been many in my own field. Unless I'm dropping lines or coding people in the ICU, my job is a lot of talking to people and writing long notes. It isn't all that surprising to me that I'm interested in the more procedurally oriented subspecialties.

All of which made it easy to overlook Mr. Arthur. He suffers from Parkinson's disease and dementia, so when I read that on the chart in the ER and then heard him say "I've never had a tremor before" I discounted his story, chalking him up as another demented patient with poor historical skills. I had gotten called on two patients at once, so I left Mr. Arthur to tremble in his bed a little longer while I got the much more exciting acute pancreatitis patient upstairs.

Coming back to Mr. A, I got his story a little clearer. He was worried. Worried that his home blood pressure cuff was giving widely variable readings, worried that the ER doc told him his heart was in trouble because of "a tremor in the way it beats" (the ER resident meant atrial fibrillation) and worried because his baseline tremor was getting bit worse. I was able to fix one concern right away, (and this illustrates my irritation with the ER residents) by just looking at his EKG. There was certainly an EKG showing atrial fibrillation in Mr. Arthur's chart, but the problem was it said "Betsy Rosengard" across the top. Mr. Arthur's EKG was not completely normal, but it certainly hadn't changed from the last time he had been admitted, a year previously. The tremor I wasn't sure about, but his blood pressure concerns, especially in a 90 year old man, were enough to warrant at least a 23 hour observation period. I got him upstairs and promptly was swamped by the other 30 or so patients requiring my attention.

Later that night, I was going through Mr. Arthur's clinic notes in a bit of downtime, and I noticed that his primary neurologist mentioned he was a writer. I checked his name on Amazon and found that my patient had written 11 books, several on the Korean war, in which he fought, and a few on other American conflicts. So when I swung by his room on my evening rounds, I asked him about it. He brightened up immediately, and began telling me his life story. Though his mind wanders at times, he is still quite sharp, and he told me about joining the Canadian Army in 1940 because he was desperate to "kill them Nazi bastards." While there he met King George VI. He transferred to the American Army after Pearl Harbor and was made a tailgunner in B-26s. He didn't want to fly and so transferred to the infantry, where he went to Germany after the surrender to guard POW camps. He still remembers the names of the SS officers he was charged with keeping under lock and key. After WWII he came home and married, staying in the Army and going to Korea, where a lot of the experiences in his books come from, apparently.

I was amazed I had ever seen this fascinating man as just another patient. I realized that I just hadn't given him a chance to tell his story, and that all of his concerns were valid, he just didn't talk fast enough to convince me in the 30 seconds I had given him.

I didn't want to leave, but I had to let the man rest, and I had other patients to see, but I came back to his room the next day and chatted for over an hour after I had signed out, and could have been at home, asleep.

I may regret not sleeping that extra hour this afternoon, someday, but I doubt it.