People ... who can understand them?

So, the patient I was writing about, the man who's been bedridden for four years. To make his history short, he's status post left renal transplant and pancreatic transplant also. I mentioned in my last post that he has issues with depression. Well, today, some smart-ass Doctor who's never even worked with him before, goes into his room and tells him that his pancreas has failed. His blood sugars have been high because he's been on steroids to deal with renal transplant rejection, and while the pancreas is also being rejected to somewhat of a degree, it's not technically failing yet. Yet this Doctor, without even speaking to the patient's parents first (who were out in the waiting room), goes in and tells him his pancreas has been rejected. The man was in tears when I went in to remedy the situation. He wanted to sign out AMA and I told him I didn't blame him one bit. I called his Attending, and we discussed. His anemia that had brought him in (the reason for his admittance) was now better resolved after 4 units of red blood cells, tho not optimum but it was enough that he could leave. His urinary tract infection had resolved. He hadn't had fever for days. His strength was better. Granted, his BUN/creatinine was still elevated and his blood pressure was high, but he could go to dialysis and get his prescriptions at the pharmacy just as easy as he could in the hospital. So, the Doctor said he would sign him out first thing in the morning, to which the mom emphatically shook her head no, to which the Doctor said, "fine, sign him out AMA then." So, that's what we did. They called their ambulance service and he should be leaving right about now.

My main issue here is the insensitivity, not to mention the incompetent behavior, of the Doctor who conveyed this 'news' to the patient. She didn't know a thing about him, yet she took it upon herself to relay this (wrong) information. I came across this earlier, with a different Doctor, after I attempted to bring Physical Therapy on board. He's been in bed here for 2 weeks, and while the nurses turn him every so many hours, to ward off bedsores, he has a pressure ulcer on his left heel that's already reaching grade 2 or 3. I wanted someone to work his legs to better his circulation and also just to help keep his muscles from complete atrophy. The Doctor said, "sure, although I'm not sure what good it's going to do him NOW" ... right at the door of the patient.

I could have strangled him. I understand that things get busy and sometimes we forget that patients are real people, listening to our every word. But I mean, really, is it so difficult to move down the hall or even go into the Physician lounge to state your case? And in fact, the Doctor was in fact wrong, just because someone is bedridden with little hope of walking again is no reason to think that PT will do no good "NOW". It can still do a LOT of good "NOW".

To make things even worse, the patient had said that if he could get into a wheelchair he would stay. I had been off with other patients when they all tried to get him in. If I had only been there, I lift heavy weights and even though I have a bad back from years of lifting boxes/concrete/hay, I KNOW I could have gotten him into that wheelchair. Just the fact that he asked to do it sends a strong message. So, when I was with the family later, I told them about a lift that I used with a woman with Multiple Sclerosis who I took care of for a few years. It's a hydraulic lift that has a belt attached to a chain that raises up with really minimal exertion on the part of the person who turns the crank. I just got home when I remembered that I hadn't told the family how they could get one, and in fact realized that I myself don't know. So I called his nurse, who told me that would be something they would request through their social worker, and she said she would relay the information to the parents before they left with the transport ambulance.

We could have gotten him in the chair. I hope they follow through with that.

Tough times.

There has been a tragedy in my life and I'm trying my best to immerse myself in my education and work. Some days are easier than others, but there is nothing else to do. Sometimes life deals heavy blows and all we can do is keep going. There are others who have gone through worse. All we can do is survive.

Life is a gift. Or is it?

This last week I've been working with a patient who got meningitis and now four years later is bedridden and unable to move. He was a normal man before that happened. His mother and father take care of him now completely themselves, from bathroom to feeding. I spoke with his mother who told me that the reason he refuses treatment is because he wants to die. He is most likely going to need dialysis soon and he's told her that he'll refuse that too. If that happens, then he will die. A psychiatrist comes to the house twice weekly for him. I made a few suggestions that might help, getting him a computer (his right hand moves enough that he could type), perhaps learning a skill such as a new language (he likes Italian).

Sometimes life is sad.

Well, let's see.

I got here at 7 this morning, it's 7 pm now and there's no way I'm leaving for another few hours. I just finished up with all the patients, but now I have to stay in the library and begin my submissions that are due at the end of the week ... two 7 page papers and one 2 page paper. Plus one of our top Attendings gave me a paper on Acid-Base Disorders that she's going to quiz me about on Thursday. I just inhaled a salad. Do I have time to check my email? Okay, back to work.

Moving into the 3rd week.

Last week was so busy, man do my feet still hurt. We have a board review exam coming up the day after the exam for this rotation, so I've been having to study after work until midnight and thus have gotten 5-6 hours a night for the last 7 days and it's wearing me thin. Then again, pain is weakness leaving the body ... I'll sleep when I die.

Lots of patients. Most are great, but a few are rarely just plain stupid. We had one guy sign out ama (against medical advice) because, even though we had just taken a liter of fluid out of his belly, another liter (filled with pus and blood) from the spaces around his lungs, and found two pulmonary embolisms in his lungs as well, he "felt better" and would "goto church and pray". We begged, we pleaded, we yelled, and ... off he went. He was so uneducated and ignorant, he actually thought we were keeping him there to practice procedures on him as a human guinea pig. Oh well, sayonara dude. Next.

There was one day when my resident had an interview for something, and my intern was called to another part of the hospital for the rest of the day, so that left myself and the 3rd-year medical student in charge. We rocked. Did what needed to be done. My resident's wife, also a resident in the hospital, had his pager, and I would just call her with orders to put into the computer after I saw each patient. "Okay, no problem", she would say. Gee whiz, I felt so grown up! Soon enough, can't wait. I'm proud of my decision-making thus far, I'm going to do just fine.

Moving into the second week.

Last week was a challenge, not only in that it's a new rotation with a new team who all have to get used to one another, but also because none of them really knew anything about PAs or PA education. So, I sat them down at lunch and answered all of their questions. They had some misconceptions ("you don't take call, right?" "you have much less responsibility, such as not having to work on the weekends"), but all that took was some gentle correction. All week I saw their eyes widen as I relayed my knowledge about certain subjects. Then again, they're talking to someone who has a neverending thirst for knowledge, especially when it comes to physiology. But, in all fairness, I have to admit that much of what I knew in front of them came from my recent teachers (and a bit from you too, Ms. O).

Today we worked with an attending in Transplant Nephrology, and I mean this man is a D.O.C.T.O.R. Brilliant. All I could do was hang on his every word. He had us all come down to the pathology labs where the Pathology M.D. took us through the biopsy slides in detail, using large digital wall screens that are connected to their microscopy equipment. I was just in awe the entire time; they pointed out the glomeruli, the nephrons, the pathology, the immune response. It turned out that the patient has borderline transplant rejection (4 years ago), but the organ is still working well enough that there is hopefully time to change some meds and improve the situation.

Other than that, we just continued on with our patient care, monitoring labs and meds, changing labs and meds, ordering procedures, performing procedures, consulting with surgery/infectious disease/CAT/MRI/cardiology/GI constantly. Busy busy.

Now I'm home, I've had some soup and put my feet up for a few minutes, and it's time to fill my water bottle with some vitaminwater and head back to the library for a few hours of study. Then it's up at 6 for ... Tuesday! :)

First day.

Good resident, good intern, good medical student ... I lucked out. Only a handful of patients at a time (today we had 5), but they are so multi-presenting that there was no lack of things to take care of. Dialysis monitoring, insulin regulation, nutritional consideration, meds, labs, charting. My background education in physiology is coming into gear at full throttle. Many, many details to keep track of.

One of our patients is an older woman in her 60s, who has ESRD (end stage renal disease). She has hyperparathyroidism, which is resulting in high levels of calcium in her body. The calcium has nowhere to go, so it deposits in the tissues, including blood vessels and the valves of the heart. She is being given a calcium-binder, but it can only do so much ... she needs dialysis every day for a minimum of 4 hours. Problem is, she is non-compliant and leaves after 2 hours. I'm not sure she understands that she's basically killing herself because her blood is not being properly cleansed of the overload. I saw her in dialysis today and reminded her that she needed to stay as long as possible, and made sure she had a TV to watch. She'll be getting an X-ray tomorrow to look for blood vessel calcifications in her legs. Oh yea, that's the other thing about this patient, her legs and feet, due to the lack of adequate blood supply, are dying. They're developing sores which can't heal and she will most likely need amputation. Very sad, but even more tragic when you consider that her lazy attitude is such a strong contributor to her condition. You can lead a horse to water ...

I'll be given my own patient(s) to follow tomorrow, so I'm really looking forward to that.

Next up ...

Nephrology.