the patient that broke my heart

This will probably be one of the few posts i will put up in retrospect from internal medicine. Our assignment was to think of a patient encounter that stuck out to us. I wrote it from my perspective, and hopefully from the perspective of the patient.  All the students then sat in a circle and read their stories to each other.

The Student

Her pager rang and a number showed up. Someone must be in the ER, she thought. She called the number back and the resident briefed her on the patient, explaining his cause for coming in. “Oh yeah, and he has Parkinson’s, so you might see some good physical findings.” She knew the basics of Parkinson’s disease because in the second year of medical school, it was her job to know those signs and symptoms. Nevertheless, this was not her first trip to the ER and she knew to expect anything when walking into the patient’s room. She was told how he came in initially for right facial droop – or was it left? It did not seem important – the point was that he had some kind of change that was noticed by his home health aide. After preparing the H&P with the appropriate information, she rounded the corner to room number 7. Immediately, she noticed his eyes were closed and his mouth was slightly ajar. “It looks like someone’s sleepy.” The wife sitting in the chair on the right with her daughter quickly corrected her. “He has trouble keeping his eyes open because of the light; he’s actually awake.” An immediate realization struck the naive medical student:: the patient was stuck in that position. Her head initially reeled, and upon finding her bearings, she quickly slid back into her routine: HPI, PMH, ROS, PSR, FMH, PE. She found nothing calmed the nerves like patterns did. She started asking a question, but then faltered, not knowing who to ask. Could he speak? He looked frozen. After several questions, she finally mustered the courage to ask him. She had overcome her fear of something different. It seems as though it does not matter how many times she walks into an ER room, there is that initial shock which is probably due to every preconceived notion with which she was raised and those same notions generally encouraged throughout medical school being torn apart by the patient.

As he began speaking, his jaw unable to move, she strained to listen to him. It was like listening to a ventriloquist who is just starting his training: words slurred together, the second indistinguishable from the first. He cannot talk loudly either, which forces the medical student to lean over the bed with her ear close by. At first the wife and daughter help her out, but she eventually begins to understand him. It becomes easier and she is able to stand a little straighter. She realizes this man has no real mental deficit by her standard. After getting the typical information required, she starts the physical exam. He follows the commands as she asks, first by giving her his hands. She moves through the physical exam, and asks him if he can open his eyes. Slowly, he raises his hands to his eyes and opens them with his fingers, and beneath those lids his eyes were a brilliant blue. Again, another example of that subconscious expectation shattered by the surprises the patient tucks away. She progresses through the exam as taught and reaches the feet.

Not being a foot person, this is usually her least favorite part. His shoes are still on. She talks as she takes off the shoes, and the family shares how his feet get cold easily and how he can get cold easily, in general. She gets to the socks and notices the smell which always causes some initial guilt for noticing that they smell. Nevertheless, she marches on, determined to not neglect this site. She feels for the pulses, palpates the calves and does the other steps until she reaches the Babinski reflex. She forewarns him she is going to run the hammer down his foot. As she proceeds to do so, he starts kicking his feet and smiling. That was first when she realized he was not just a patient. She laughed too, along with the family, commenting on his playfulness. Next came the testing of his strength – he seemed eager to show how strong he was; and he was. After the exam, she spoke with the family for another 5 minutes, answering any questions they might have. She immediately noticed the wife was asking many questions and the concern was apparent both in her voice and on her face. The daughter had the same concern. The family, knowing their loved one was safe for the time being, decided to go in search of food, and as the medical student said good-byes, the daughter asked, “Wait, you’re Dr….”, the student caught off-guard immediately attempted a correction, “Oh no, just call me-”, “Okay doc”, and the daughter walked away. 

Patient           

I did not notice a change, but my health aide insisted something was different and called my wife upstairs. After some deliberation, they decided to call the hospital. Things happened rather quickly from that point on. Some group of people stood over me asking questions, asking me if I knew the year and knew where I was. A stroke? I felt the same as usual.  After some time, apparently the change disappeared and I was moved to a new room. I sat with my wife and daughter for awhile in the brightly lit room. My eyes tend to get really sensitive to the light, and the light in the ER was definitely causing me some discomfort. My eyes reflexively close. It is always frustrating to have to open them with my hands, but over the years I have grown accustomed to the changes my life has garnered.           

After awhile I hear a young women’s voice. She says hello and is very polite, and initially assumes I am sleeping. It was a little embarrassing, but I am unable to really show embarrassment any more. She introduces herself, and starts to ask the family questions about what happened. She did not really ask me anything at first, and mostly my wife answered. I did not actually mind because really, my wife has always answered for me. After sometime, she started asking me questions, with many of my answers being difficult for her to understand. She sounded patient, and sometimes she would switch her question to one I could answer with yes or no. She asked a lot of questions, many of which the other doctors had already asked. Then, she switched to doing an exam. She poked and prodded for a little while, shined lights in my already sensitive eyes, asked me to say “Ah” when I cannot move my mouth. I just did what she asked, not sure how this would help get me out of this room. She went through the exam and got to my feet. She ran this cold piece of metal down my foot, causing it to tickle, and without thinking I just kicked my foot and laughed. I caught her off guard making her laugh, and everyone else in the room. After hours of the tense atmosphere, it was a relief to hear something other than the beeping noises in the monitors. She then tested my strength, and didn’t hide her surprise at finding me so strong. I couldn’t help but be flattered.           

She told us that more people would come to talk to us, to help decide if I should stay in the hospital. These people came and went, and soon I was being wheeled to another room. I didn’t hear from anyone for hours, but didn’t mind so much because it wasn’t as bright. I laid in bed not knowing really what was next. They said something about maybe a “TIA” or “transient” something or other. It did not matter so much to me, I was really just hungry. Normally, my wife will cut up my dinner for me very fine and feed me despite my stomach tube. Nothing can possibly compare to her cooking. Even after 60 years, I would still her prefer her cooking to anyone else’s food. Early the next morning, the girl that talked to us the day before came in. She came back awhile later when my wife was there. She told me I could not eat yet, and I probably would not be able to for a couple days, and definitely not by mouth. It was difficult to accept, but she explained the risk of me eating by mouth. To be honest, I did not care too much about the risks, but now that I was here, it did not matter. She was my only way to food, regardless of the route. My wife begged and pleaded, but her wily ways only work on me. After that day, the girl came and saw me every morning, and sometimes in the afternoon as well.  A couple times she came up because the nurse had told on me about pulling out the needles or taking off those weird things on my legs.            

I still remember the first time I took them off. I wanted to sit in the chair in my room, so I sat up, and started tearing those things off my legs. I got them off, and sat in my chair, stilling holding the leg things in my hands. Some nurses came in and tried to take them away from me, but I held onto them refusing to let go. I didn’t want to get back in bed yet and I especially did not want to put those back on. Eventually, three of them tore them from me, but they didn’t attempt to put them back on me. I was put back in bed, though. The next morning, the girl came in. “So you don’t like having those things on your legs?” I managed a “No”. She then proceeded to ask me politely if she could put them back on for at least a little while, explaining that they would keep clots from forming in my legs. I told her she could. She had asked so nicely, and I did not know that’s what they were for.

I still took those clot busters off from time to time, and it was inevitable that the girl would come in one of the times I was taking them off. I had been graduated to having these weird fluffy shoes, too. She came in and laughed a little at my predicament, and I laughed too, knowing the scene I was making. I can only imagine the look on my face, the typical face of a person caught red-handed. I know I cannot make many expressions, but somehow, sometimes I can still manage to get some emotions across. She walked in, “Here let me help you…you know, if you want these off, you should just ask the nurses. I am sure they would let you take them off for a little while.” I doubted they would. I know had I asked, the nurses would have told me they are there to help. The girl did too, she told me what the new boots were for, but she didn’t make me put them back on right away. Then, I got the chance to laugh at her predicament. As she took all the contraptions off, the Velcro kept attacking the other pieces of Velcro, and she just couldn’t manage to tear them apart. She laughed at herself, and asked me why I had to cause her so much trouble. I laughed a little too, telling her I didn’t want to cause trouble. We had many moments like these.

There was one day that was very difficult, and I know it was not easy for her either. It was the day we talking about my leaving the hospital. The girl and some other female told my wife and I that ultimately, I should be in a nursing facility. I was horrified. A nursing home? I could not possibly live in a nursing home. I know my health is not great, but I could not possibly really live in one of those. That would kill me faster than any ‘asper-something pneumonia’. They spoke with us for awhile, about at least considering it initially, just for the physical therapy so I could get my strength back. In the end, I did have to agree I needed to build some more strength. I also knew I would not stay, despite their recommendation. Even if I spent fewer days at home because of some accident, I would rather spend those days with the family I love, than in a nursing home without them.

I couldn’t finish reading this to the group because I couldn’t stop crying. He was a wonderful patient, and for all the aggravation his wife caused the rest of the staff, I was endeared to her because everyone of her questions represented her love for her mentally and physically degenerating husband.

and if nothing else, you got to see me use uppercase for more than yelling.

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