Thursday, March 13, 2008


The certainty of death is attended with uncertainties...

Mrs. Harding is not the kind of woman who seeks help.

She tripped over a dog's leash and fell down the short flight of wooden stairs from her balcony to the grass and discovered she was unable to rise. Despite some pain, she managed to drag herself back inside, and into her bed, where she was when her family returned home. As they had a spare wheelchair around, she just adapted to using it to get around as attempting to walk caused her excruciating pain.

That was six weeks ago. She hasn't walked since then, but her family took her to the hospital against her will finally because she stopped eating. They convinced her, eventually, that going to the hospital, being admitted, and doing everything medically possible was the best course. I'm not sure they were right.

I did a physical exam prior to admitting her, noting her to be dehydrated, malnourished, and unable to move her externally rotated and shortened right leg. She had no medical records because she could not remember the last time she had been to a doctor.

Incidentally, I noticed that most of her upper right chest wall was being eroded away by an obviously cancerous lesion. I asked her how long she had noticed something wrong with her skin there, and she told me "a few years." She hadn't shown another soul.

This kind of story has no happy ending. Trying to fix the broken hip revealed that what was left of the hip socket was a massive abscess, necessitating drainage and debridement, but no hardware to fix the problem. It also dislodged a clot, which went to her brain and cut off blood to the entire left hemisphere rendering her unable to speak clearly or move the right side of her body. Treating the stroke with blood thinners caused her to bleed into the surgical site in her leg. In the end, there was nothing we could do except hope her stroke left her unaware of her last days.

All I could think about through the last days was her last words to me before her family convinced her to change her mind: "just let me go home to die."

I wish we had.

Sunday, March 09, 2008

No salt

Part of medicine residency is seeing at least one half day of clinic a week. And though my patients have generally been pretty good, this is by far the least popular part of the program among the interns. Here's a direct quote from one of my more humorous classmates:

"I woke up this morning and realized I had clinic. And I'm not gonna lie, I had a bit of suicidal ideation at that point."

Maybe that's too dark to appreciate outside this place. But I had another bleak clinic experience a short time ago. One of my patients showed up to see me complaining of shortness of shortness of breath and left sided chest pain. The (hopefully) future cardiologist in me was instantly interested.

"How long has this been going on?" I asked, trying to keep the excitement out of my voice as I planned for an EKG, and possibly a hospital admission.

"About three years," came the measured reply.

At this point my interest flagged a bit. It turns out that my patient, who has congestive heart failure and ought to be keeping to a low sodium diet, ate a McDonald's sausage and biscuit for breakfast. And not just this breakfast, but a fairly steady line of breakfasts stretching back, you guessed it, about three years. But, he responded, "it's only a little, little piece of sausage, and I'm not adding any salt."

I saw another patient upstairs, actually admitted for heart failure, who told an even funnier story. We asked him what a typical meal was for him, and he responded "I ate a pound of bacon and a can of green beans for dinner last night." When we told him that "that's a lot of salt, and you really need to eat less than 2g of sodium a day" his cheerful response was "oh don't worry doc, I don't put any salt on the bacon."