On Primary Care

“Sorry to do this to you again Ryan, but could you drive this patient to the ER?”  She had presented with a twinge of chest pain during sex a month ago, and some persistent nausea, but my attending had insisted on an EKG.  “Women don’t get the same typical angina presentation as men,” she had told me.  Sure enough, she had dangerous signs of cardiac ischemia on her EKG.  Dangerous enough to warrant going to the emergency room, but not dangerous enough to require an ambulance.  Of course, sending a patient whom you think is at risk of having a heart attack to drive in the streets of Chicago is usually considered poor medical practice.  So it fell upon me, as one of the many medical student responsibilities you don’t discover till later, to drive her safely to the emergency room at NMH.  I walked with the patient down to her car, trying to talk about something other than going to the emergency room.  Do I even know how to get there? I thought to myself.  She tells me she’s a lawyer, high end, stressful job and apologizes in advance for how dirty her car is.  I haven’t driven a car in over a year, not to mention it’s the one day that it’s raining cats and dogs outside.  The last guy I took to the ER was by taxi, but she did not want to leave her car here at the expensive rates.  We come upon a BMW and I think to myself oh god no, but she says “here we are.”  We clear away the coffee cups and papers scattered on the seats and she hands me the keys.   She leans her seat back and closes her eyes and I reach my first problem.  The key won’t turn.  C’mon Ryan, this is the easiest part and you’re faltering. I turn at the key to the point where I’m afraid I might break something.  Finally my patient sits up and tells me “Oh you have to push it in a bit to turn it.”  Still no success, so she reaches over and starts the car for me.  I give her an apologetic smile and get the car moving, slowly.  It jerks forward and back like someone driving for the first time as I get used to the braking system.  Then I reach my second problem, I don’t know how to exit the parking structure.  She continues to lay back in the passenger seat with her eyes closed, meditating on the fact she’s going to the ER and trying to prepare herself mentally. I circle around a few times thinking to myself, if she has a heart attack because you can’t find your way out of this place, I wonder if she can sue me for incompetence.  Finally I find the exit and she hands me a ticket to place in the machine.  Third problem.  How the heck do you open these windows?  I search frantically on the driver side’s armrest for something to get the windows down.  As I reach for the door to just open it and push the ticket in, she sits up again and finds the button for the window placed in the center near the gear shift.  Another apologetic smile.  At this point, when we enter the pouring rain and drive onto Michigan Avenue with many angry taxis, the patient wakes up, likely due to the stress of having me as her driver, perhaps more dangerous than her heart condition.  I drive slowly, I am in a BMW after all, a lawyer’s BMW.  Taxis honk at me, pass me, cut me off.  I never knew how malevolent they were until now.  We sit patiently at a red light and my patient turns to me and asks “Am I going to be alright?”  I try to explain to her the worrisome signs on her EKG, the need for further evaluation and the hopes that everything will be fine, or that if something is wrong, it will be addressed quickly.  A taxi honks at me to go again, the light is green.  We make it to the ER, I hand her the EKG taken in the office and explain to the triage nurse her story.  I ask if my being a medical student could speed her through triage into the ER.  It did not.  I park the car, without a scratch mind you, and bring the keys back to her.  I realize that despite my horrid driving, she only had one thought on her mind during that whole trip, and it wasn’t my driving.

On Psychology

He was an absolute jerk, involuntarily hospitalized for making threats against his parents and neighbors with no clue that what he did was wrong.  His parents still paid for his room and board at an apartment nearby that took care of psychiatric patients, but lately, he was convinced that the medications were poison, that the food was poison, and that the caretaker was somehow in league with his parents.  He would leave notes, phone messages, even stand out in the yard and yell profanities and threats, all the while talking about how his parents were trying to kill him.  At some point, the police became involved, and he continued resisting, resulting in his arrest, but this only seemed to make things worse.  He wanted to find out who had called the police and he wanted to have revenge.  When his parents refused to tell him, he blamed it on the neighbor, who apparently had been nice enough to offer him a job.  He had been working at this job for a few years, but was convinced that he wasn’t getting any promotions because the neighbor was just using him for cheap labor.  And this is the sort of person we were presented with.  Blaming everyone and everything but himself for his problems.  His entire mind was focused on getting out and getting even with his parents, his neighbor, whoever he had chosen to blame for the day.  We encouraged him to go to group activities while being in the psych ward, but he chose to hole up in his room.  Our attempts to talk to him and even confront him about his defiant nature led to denial and even walking out on our team as we were still talking to him.  We tried to get him to admit that we could help him find housing, help him with physical therapy for his back pain, but only if he voluntarily admitted himself.  He knew however that we could only keep him there so long against his will and opted for this route instead.  So there I was, taking care of someone who didn’t want to be taken care of.  Every morning I saw him, I got a curt response and a request to leave him alone.  It didn’t bother me though, I would leave him alone as requested.  We brought the parents in to try to get a better sense of his issues, but all we really saw was how dysfunctional their relationship was.  The parents would yell at their son who would continue to accuse them of smothering him while demanding that they pay for his rent.  It devolved into something akin to Jerry Seinfeld.  Throughout the few days we had spent with him, each meeting ending with him storming out angrily and shouting “You can’t keep me here,” my attending noted he had some schizophrenic features of paranoia.  We started him on a low dose of antipsychotics, and slowly over the next few days, he became a different person.

He calmed down, signed in voluntarily, spoke intelligently to the social worker to come up with a plan for where to live more independently.  He apologized to us, he apologized to his family, and became a normal human being.  His transformation was amazing, from an antisocial grumpy man who wanted nothing to do with us to someone who felt guilty for his actions and wanted nothing more than to make things right.  It was as if he was apologizing for someone else. It was odd to me how he came to us, involuntarily, closed off from any help we wanted to offer him, and something as small as a low dose of medication could change him into someone else.  Someone who wasn’t selfish, who didn’t blame everyone else for his problems, who actually wanted to make nice with the people around him.  It makes me wonder how many jerks out there would benefit from a low dose of antipsychotics.

On Neurology

A lone patient sat facing the thirty some physicians and doctors-to-be with a pleasant enduring smile on her face.  “Now say ahhhh…”  and the thirty of us tried desperately to peer inside her mouth to see the rare physical finding of a myotonic palate characteristic in MS.  Chairman’s rounds were what they called this oddity, where the chairman would perform his physical examination for all the residents and medical students to see.  One unsuspecting patient with interesting physical findings would be asked if they would like to participate in Chairman’s rounds, and if they agreed, as many of the residents and students that could pile into the small patient room would enter.  Some of us couldn’t even make it into the room and were forced to stand in the hallway on our tiptoes to see.  As the chairman poked and prodded the frail woman whose body had been weakened by MS, the rest of us gazed onwards, trying to pick up on microfindings, and improving our own exam.  She seemed very unworried by all the tests that the chairman was performing having had a lifetime of these tests.  She seemed unconcerned that she was dressed only in a thin patient’s gown draped precariously over her thin body even though she was surrounded by so many people wearing their Sunday’s best and a white coat.  She had a knowing smile, and put up with the prying eyes that surrounded her.  “Now if you would please take a few steps for us,” asked the chairman, testing her gait.  She rose unsteadily to her feet, an act she had not done for some time, and tentatively took a few steps.  “You can see here her shuffling gait displaying the extreme atrophy in the muscles of her legs.”  She stumbled.  “and her inability to compensate the slightest of missteps.”  We all looked on as she fell, nodding and agreeing with our chairman.  The chairman continued to speak of her weaknesses, demonstrating them for all to see how badly MS had wrecked this woman’s body.  He spoke frankly of her losses, without a thought as to how she herself must have felt as she herself had discovered these losses.  After any of the chairman’s findings, we were all eager to test our own skills on the patient, to see if we could elicit the same weaknesses.  Yet despite all this, she complacently agreed to our demands with a soft smile on her face, trying her best to follow our finger with her eyes or lift her leg up despite knowing she was unable to.  One by one, we lined up to examine her, and one by one, we left the room, leaving her again to be alone with her battle with the disease that was slowly taking her body from her.

On Medicine

Now let me preface this story by saying none of my patients have ever died while on my service except one.  Not the guy who got his arm run over by the El, not the guy who was shot in the back of the head, three times in the chest, twice in the abdomen, and three other times through his arms and legs, not even the little girl who ate enough lead paint chips that it showed up on x-ray.  All of them made it through, even had good neurological function afterwards.  All except one.

Every morning he’d be the highlight of rounds, jovial and friendly, always speaking frankly and bluntly to us about his thoughts on his condition and life in general.  He would always be up and about early in the morning, and when we’d ask where he’d been, he’d always give us some new euphemism for going out for a smoke.  “I went to go check the smog,” he said with a wry smile.  He had a long ponytail that had gone completely white, and although I didn’t know which war he fought in, he had the look of a Vietnam veteran.  He had a tanned, leathery body that was kind of sagging in places that used to be filled with muscle as well as a spleen the size of a basketball that made his stomach distended.  He was a frequent visitor of the VA, due to his reluctance to start chemotherapy for his leukemia.  Every time he came, we would tank him up again with blood products, counsel him on starting chemotherapy to which he would say “I feel fine, really,” and he’d hop on the bus back to Indiana.  The nurses knew him well, he’d always sneak off when blood draws were required and come back smelling of smoke, with a bag of the VA popcorn, or something else bad for his health.  He’d barter with the other patients, trading them smokes for candies or offering to buy things from the store downstairs where he got his cigarettes for the patients who were a little less mobile.

However, one admission, he had gotten significantly worse, even underneath his tan, we could tell he was pale.  His red blood cell count had fallen so far that he was unable to get around without a wheelchair.  “Tell me doc, am I gonna die?  Just give it to me straight.  ‘Cause if I’m gonna die, I’d rather do it at home, taking a long drag of my cigar and drinking a cold one!”  We reassured him that with the right blood products, as always, he’d feel better in no time, and we pushed the idea of chemotherapy a little more.  This time, he sullenly agreed, and as he improved over the next few days, retaining his color and his good-nature, he began to work out plans on how to commute here from his home in Indiana to receive chemotherapy on a regular basis.  He’d again crack jokes and chat with nurses, patients, and doctors alike.  One day, I passed him in the hallway, lined up next to another patient in a wheelchair.  “We’re gonna race, shhh, don’t tell those damn nurses.”  He hated being in the hospital, and would ask us every morning when he could leave, and oftentimes, I would see him just sitting in his wheelchair looking outside.  “I’m gonna go get some fresh air,” he told us one day, another one of his euphemisms for smoking.  We went back to our team room, finished notes, and left the hospital late that night.  We passed by him as we left, sitting in his wheelchair, eating an ice cream cone. “We’ll see you tomorrow morning” we said, and we promised him that indeed we were discharging him in a day or two.  His blood counts were all back to normal except for his white blood cells, which we did not transfuse due to its tendency to cause allergic reactions if given in large quantities.

That night he developed a fever, something that happens often when your body lacks white blood cells to fight off infections.  The covering team ordered antibiotics, the appropriate treatment in this situation, but forgot to specify that they were to be given immediately.  Instead, they were given the following morning, the default time when most medications are given.  By morning, he was unresponsive and breathing shallowly.  Rounds took forever, as per usual, and we did not see him until later in our rounds, as we assumed he was doing fine, ready to be discharged.  We had heard from the overnight team he had gotten a fever and had already received antibiotics and so we were less concerned.  He was septic, without the antibiotics, the infection had spread quickly through his bloodstream.  We quickly attached two large bore IVs and literally began squeezing fluid into his veins.  The antibiotics were flowing in, but too late.  He was transferred to the ICU the same day.

In the ICU he recovered somewhat, enough to have a conversation about having a breathing tube put down his throat, but never recovered his good spirits again.  He adamantly refused, despite barely being able to breathe due to the fluid that was filling his lungs.  The resident in the ICU patiently explained that it would be a temporary procedure, one that would allow him to breathe and fight off the infection.  The tube would be removed at a later date.  He reluctantly agreed, and fell back into a coma.  It was heartbreaking to see him, collapsed in his bed, surrounded by millions of tubes and wires, with a cold blank stare and no trace of the man he once was.  Later that day his heart stopped, but we wouldn’t let it stay that way, a code blue was called, and his heart was made to beat again for a few hours before failing once more.  Again the rescue breaths, the rib-cracking chest compressions, and the electrical shocks to the heart, and the medical miracle of CPR once again brings his tired heart to beat.  His sister came in the next day, and the resident discussed with her what the patient would have wanted in this situation.  The answer came easily, “He would’ve never wanted any of this.”  His heart stopped again a few hours later.  The breathing tube was removed.

To cope with this tragic loss, my team reviewed the proper management of neutropenic fever and septic shock that sent him to the ICU.  We studied the ARDS that kept him from breathing and required emergent intubation.  We learned about properly assessing if a patient should have a do not resuscitate order.  It was all just this cold regimented rehashing of information.  I just remember how he looked with that ice cream cone the day we left, the day we promised he’d get to go home soon, the day we said “We’ll see you tomorrow morning,” and went home to our beds as he fell into a deep sleep.

On pediatrics

I passed by the colorful bowl of lollipops and enter the pediatrician’s office where a jazzy version of “When you wish upon a star” is being played on the digital piano that takes up his entire desk.  “Do you play?” he asks me, to which I say, “just a little bit.”  “Play! Play something! The stage is yours.”  Being my first day of pediatrics, I think to myself, will this performance be factored into my final grade? “Ah, that scale was nice, what was it, fourths on an pentatonic F?”  I shrugged my shoulders and mumbled something about having poor music theory.  “You like jazz?” asked the pediatrician as he walked out a bass line, “improvise something!”  I tried my best to keep up with the chord changes that seemed to happen smoothly and irregularly at the same time.  “Not bad! You got talent, but when you improvise, you have to feel it, you have to mix your soft tones with your loud ones.  Make a statement!”

Throughout the next few weeks I spent there, I continued to pick up lessons from him.  He was an odd character, almost out of a cartoon.  He’d perform magic tricks, tell jokes, and always seemed to be singing.  He’d love to take patients or even the parents to his digital keyboard where he’d hash out some jazzy improvisation made just for them.  He’d inspire kids to play piano, leave them wondering about his magic tricks, and have them coming back for more of his jokes.  Imagine, a doctor who’s patients want to come back to see him.  It’s difficult enough when your patients are responsible adults.  Yet somehow, he had made his office into somewhere safe and fun despite the pokes and prodding of the physical exam and vaccines.  He layered on the jazz lessons, giving me tips to improvise, good chord progressions, and how to play with flair.  I felt like most of these lessons, except maybe the chord progressions, were life lessons as well.  I’ll never forget though, walking into his office that first day.  It was like walking into a different world, finding something completely unexpected, and somehow made me feel like a kid again.