In yet another assignment to hone my interviewing skills, I found myself on a hospital ward this week asking a charming patient about her medical conditions. Though it wasn't what had brought her to the hospital this time around, I soon found out this fairly young lady was battling pancreatic cancer, and could no longer work due to the severity of her condition.
"I come in twice a week for my chemotherapy. It hasn't really helped yet, but I don't think I've been on it long enough for it to start curing the tumor," she said, fidgeting with the Natural Cures for Cancer book on her lap. "I'm pretty optimistic that I can beat this."
I was inspired by the patient's courage. Given her dismal condition, it was nice to see there was a ray of hope promised by the treatment.
Before I presented the patient's story to my preceptor, I obtained some collateral information from the chart as I had been asked. From what I read there, however, any ray of my hope in my mind quickly dimmed.
I'd had a feeling during the interview that something wasn't quite right. While I'm not a doctor yet, let alone an oncologist, I do know that pancreatic cancer is pretty serious. But, I had taken her on her word that there was an encouraging outlook. Perhaps her type of pancreatic cancer responds well to chemo, I thought.
What I found in her chart confirmed my initial suspicions:
"Patient has Stage IV advanced pancreatic adenocarcinoma, receiving palliative chemotherapy."
Though palliative chemotherapy can help with the pain and other symptoms of cancer, it's not provided with the intention of "curing the tumor."
Maybe nobody ever fully explained to her the role of palliative chemotherapy. Worse yet - heaven forbid - maybe she hadn't even been told that her therapy was palliative.
But the situation probably wasn't either of those. Because right after that, the physician had written,
"Patient is in denial with regards to her condition, despite numerous discussions regarding prognosis."
When I discussed the case with the doctor, he explained it to me another way. "Barring a miracle, the flowers in her room will last longer than she will."
I still wonder if I should've gone back to her room to say goodbye.
Tuesday, February 05, 2008
"The chemotherapy hasn't helped yet, but I can beat this."
Sunday, September 30, 2007
Getting used to palliative patients might take some time.
For our clinical skills classes, we spend most of our time on actors / standardized patients, who come into our clinical skills training rooms at the hospital and we learn how to do basic exams on them.
However, the odd time we'll go onto an actual hospital ward and get the opportunity to examine symptomatic patients.
Last semester we were at the hospital practicing our cardiac exams on a couple of hospitalized patients. My group was assigned a patient who was really friendly, and such a great sport - she didn't complain once about the four medical students percussing and auscultating her chest, tapping for a lung here, listening for a murmur there, asking her to sit up and lie down, even though it was obvious that due to her bad back the ordeal wasn't entirely pain-free for her.
Over the twenty or so minutes we spent at her bedside, she told us more and more about her condition, but she also talked her life - her job, her family, and the things she enjoyed doing before she ended up in the hospital. She wasn't too old, and she was pretty coherent. She seemed like a really nice lady, and I really enjoyed the chance to get to know her.
After our exam, we went to the nurse's station with our physician tutor, who called up the patient's lab tests and CT scans on the computer. We talked a bit more about the patient - she had a few other conditions that weren't related to our cardiac exam which we briefly talked over - and then were ready to move on to the next one, when the doctor said something that hit me like a truck.
"So that's Mrs. Walters. With all of that going on in her body, she doesn't have much longer to live."
I was shocked. I had just spent twenty minutes with this patient. She seemed to be functioning cognitively pretty well, and I figured she was in the hospital getting fixed! Never in a million years would I have thought she was about to die.
The seriousness of her situation started to set in, and from a medical perspective I realized that yeah, if I had been given this patient as a narrative case, I probably would have figured out that the prognosis was dismal. But because I met the patient as a person first, and didn't know all the details of her condition while I was talking to her, I hadn't really thought about what her prognosis was. Even while our tutor was going through the patient's chart, listing her conditions, the impending outcome of the sum of her conditions never hit me until the doctor put it into those words.
I suppose that now that I think of it, I might as well get ready for my clerkship year next year, when I will be meeting dozens of patients on a regular basis - some of them who don't have much longer to live. I've never really been in that situation before, and I think it's going to take some getting used to.
Wednesday, October 18, 2006
Post-ER-shadowing Advice
[Formerly a part of the post Back in the hospital: ER shadowing]
Advice I got from the MSIII at the hospital:
Advice I got from the ER doc I shadowed a couple months ago, and was reiterated by my own personal experience:
And my final piece of advice, from the R1:
Back in the hospital: ER shadowing
School is great so far, but the general basic biology review that comprises our first term is a bit slow and lacking in clinical experience.
Things will brighten up when I get my stethoscope / otoscope / opthalmascope next Tuesday. Also that day, I start my first of four experiences in a family physician's office, which is going to add an exciting element to my medical education.
The doctor I'll be shadowing seems pretty cool, and excited to have us, which is nice. He sent me an e-mail that got me really excited. Part of that e-mail:
In my office, you will be doing more than just talking. I expect you to do limited physical examinations under my supervision. So yes, bring all your instruments. You will also have a chance to do some minor procedures, like giving shots or taking out sutures. In another word, you have to work. Flu shot season is coming up. Hopefully you will be an expert in giving shots by the time you leave.
I hope you will have a good experience and at the same time, have some fun. Books can be very boring.
That's all you need to tell a med student to get them very excited. As well, his practice is about 60% Chinese, "so polish up your Cantonese." And, I don't have to wear a tie. Nice.
Though I'm required to get that experience, I'm still trying to get some more exposure to the specialties I'm most interested in right now, namely, OR and ER. I finally have had enough of trying to smother my itch for clinical exposure and signed up to shadow an ER doc for a couple hours yesterday. Our school has a comprehensive online list of about 100-150 local docs in all sorts of specialties who are happy to have med students to shadow them, so I looked one up, and yesterday found myself wandering towards the big city hospital a short walk away.
I haven't been orientated to that hospital, or any hospital here for that matter, so I wandered in through the paramedic ER entrance, put on my short lab coat in a hallway and wandered over to meet the doc.
The doc I was following looks EXACTLY like a younger, shorter, blond Greg Kinnear. I kept doing double takes all night. He was great to shadow; it was pretty busy and he also had a R1 (first-year resident) and a MSIII (third-year medical student) following him around, but he was happy to have me there.
It's only the second ER I've ever shadowed in, too, so it was neat comparing the two places. This big city hospital had all sorts of neat stuff: a very belligerent HIV+ homeless individual who got drunk on rubbing alcohol and bumped his head and subsequently cussed out the doctor at full volume when the doc tried to get info about his HIV condition; a lady with alpha-1 antitrypsin, sepsis, lung transplant (alpha1 is one of the few conditions we've actually learned something about so far); a 50-year-old Fijian gentleman who had recently had a SEXTUPLE bypass (never heard of that before)!
It was also my first experience with actual teaching-hospital-attending-doc pimping, something I had only heard about to date in the medical blogosphere. The doc asked me a few medical questions, which I wasn't expecting. Fortunately, one of the ones he asked me (why do we give thiamine when we give glucose?) was something I learned this week in class. He seemed almost surprised that I knew the answer.
I enjoyed seeing what the MSIII does, as well. It'll be exciting to finally be on the floors and doing medicine and interviewing patients and doing procedures. He did a great job of presenting cases to the attending; I wonder how some of the people in my class will end up when it comes time for them to coherently present cases. At this point, at least, they don't seem nearly as confident...or competent...as he was.
[Formerly the first half of a longer post; second half can be found at the post Post-ER-Shadowing Advice]
Saturday, August 19, 2006
My First Patient: Mr. Box. Mr. Cardboard Box.
I felt like a nerd being excited to finish up my rotation with a 10:30 pm to 7:00 am shift in the ER.
So, just think how excited I must've been when the doc told me, "If there are any drunks that come in who need to get stitched up, we'll get you suturing tonight."
If there are any words which will guarantee that no more patients will come into the ER, that must be the magic spell. Between 2:00 am and 6:00 am when I went home, we saw two patients. Somewhat unusual for a Friday night.
It's probably a good thing. The rest of the time the doc and I and the nurses all sat around and chatted. Then, I did end up suturing - on a cardboard box - following one-on-one lessons with a physician. It was good to start on something that won't leave a lifelong scar. And I quickly learned that suturing is another one of those things that isn't as easy as a doctor makes it look - it's easy after a bit but you feel like all thumbs for the first few minutes. He also showed me how to hand-tie sutures
I did finally get a view of a patient's fundus using an opthalmascope, though! Well I was excited because I had tried a number of times, unsucessfully. All the more reason to buy an otoscope/opthalmascope set - so far in our registration package we've been told that only about half the class buys one; the other half thinks you can get by without one.
So that's it for me. Back to relaxing for the rest of the summer, until classes start.
I can't wait.
Thursday, August 17, 2006
Learn from someone else's mistake #1: Humour and patients
It feels good to sit down after an 11-hour shift. And, I get to sleep in tomorrow (that's the good news; the bad news is it's because I'm doing a night shift tomorrow starting at 10:30 pm.)
Story time.
As we left the patient, the doctor pointed to a dressing cart and said, "How about you put some gauze and tape on her cut so her dad doesn't have to hold that tissue paper on it."
"Oooh," I thought, "I get to talk to a patient! No doctor in the room! Awesome!"
I collected myself and grabbed a roll of tape and some gauze, and carefully put it on the ninth-grader's wound in a very amateur and untrained fashion that is probably contraindicated in every way and will cause the nurses to shake their heads and mock me under their breath as soon as they seen it. But as I left, I said the fatal line:
"That should keep your dad from having to have his arm up for the next few hours!" Ha, ha, ha, I thought. A few hours. I'm so kind-hearted, cracking a witty joke and keeping these patients smiling.
The reaction was not what I expected.
The girl's eyes went big in horror and shock.
"A few hours?!"
They had been there for hours already and had seen us walk by their room several times to see other patients - likely including patients who arrived after they did. I quickly learned a lesson from the poor girl's reaction to my offhand comment: When it comes to joking around with ER patients, they don't find it funny if you make a joke along the lines that they have a long time left to wait. Most of them have been there long enough just to see a doctor. Unfortunately, they will likely be waiting there for a while longer as they wait for labs and xrays to come back. But don't remind them. Especially in joke form.
I figure that this could be the first of many mistakes that I post here, mine and others (med school classmates beware). Yes, I have come to terms with the fact that I may do two or three things wrong over the course of my medical education. So I'll try to immortalize them as they come along in what could be a great new VM miniseries. And hey, why not just talk about my mistakes? Here's another one. One that I didn't make.
This I learned from the doc I was following: Never give a patient any definite indication of how much longer they'll have to wait. Not that you should avoid the question or lie to them. It's just that things can get crazy. A patient we were seeing was getting antsy to go home, and he asked how long he'd be. The doc explained, "We're going to refer you to a specialist, Dr. Frist. We've paged Dr. Frist, and she always responds to her pages right away, so you shouldn't be here longer than ten or fifteen minutes." On top of all hell breaking loose in the ER, this also marked pretty much the first time that Dr. Frist didn't return a page. I felt really bad when I noticed him still in his bed an hour later and went over to explain what had happened.
Shadowing doctors is great now that I'm a medical student and not just a pre-med. Maybe it's just the docs I'm working with, but I've noticed a difference. Even though what I'm allowed to do is still very limited, the doctors have that much more respect for me. I've had deep conversations with six or eight doctors where they've gone into detail on questions I've asked about about their experiences in med school, lifestyles of various residencies, pros and cons of specialties. One gave me good advice about going the military route to pay for med school. And I've been so surprised by how much they care about my future.
All the stuff they're letting me do is part of that respect. Even though it's just been little stuff like going to a patient on my own and explaining that we'll need to run some more tests, or reducing a dislocated shoulder, or putting on a cast (the last two under close supervision), it's a good feeling when the patient asks why more tests are needed and I can explain, or feeling the shoulder pop back into place, or hearing the patient say "that cast makes my arm feel better already."
It's also a good feeling that I'm no longer just doing the pre-med thing - watching. Instead, I'm practicing. For when I get to do this for real. For a living. It feels good. If I can choose to walk around an ER for "fun" for 11 hours, and still be willing to go back for another helping tomorrow (during a night shift, no less), I think this might be an indication that I've picked the right career.
Wednesday, August 16, 2006
Solemn Questions
Q: What's one way to make a macho, healthy young man cry and wail like a baby?
A: Tell him that the semi truck he crossed the centerline with killed an entire family in the minivan.
I don't recommend doing this. Trust me - it's not fun even just being around when something like this happens.
Talk about dropping a bomb. Just think of the stinging questions that this poor patient must have had swirling around in his head while his body shook with his sobs. "Will I go to jail?" "Are those cops here to arrest me?" "Am I a murderer?" "Will I ever be able to sit behind the wheel of a car again?" "What were their names?" "Where were they going today?" "How old were the kids?"
Who knows - maybe even he wondered,"Will I go to hell?" I'm not trying to be funny. Maybe that does go through the mind of someone who's just been told that it's not just their own blood on their hands. What would you think if you learned you've just snuffed out several other lives in the blink of an eye? That somewhere, sisters and grandparents and aunts and cousins are devestated; they'll be planning a group funeral for a young family? None of them were even sick, none of them should've died today or anytime soon, but they're gone now, all because of you.
Can you imagine having to deal with those questions? And after having to deal with so many other intense questions. "Why am I strapped to a back board?" "Why am I wearing a neck brace?" "Will I ever walk again?" "I make my living driving - will I ever drive again?"
"Are the other passengers hurt?"
That's the one question he asked out loud. Maybe he shouldn't have. Maybe the cop should've waited before he told the patient. Maybe there is no 'ideal' time to tell someone something like that. Here's a question - What's worse, anyways? Dying in a car accident, or living knowing that you killed someone? a bunch of people? And then later trying to get behind the wheel of a car again - to use again something you once turned into a weapon of mass murder?
I've already come to accept the fact that someday soon when I'm finally a doctor I'll be telling family members that their loved ones have passed, or don't have much time left on God's good earth. Not that accepting this fact will make it a walk in the park when that day comes. However, what happened today is one variation of such an event that I didn't foresee. I'm glad I came upon it as an observer, rather than being the informer.
I hope I never have to deal with it again.
Maybe now you can understand a bit that being in the ER for just a couple days has already made me ask more questions about myself.
"Should I really be eating this?" "Do I need to add this much salt?" "Should I choose a safer way to separate these frozen burgers?" "Do I really need to be driving this fast?"
Being in the ER has made me much more careful.
Because I've seen what could happen to me - or what I could do to someone else - if I'm not.
