Having trouble even knowing where to begin writing about my experiences with inpatient medicine. Despite knowing how sick you have to be to get admitted to an American hospital in 2008, I was not prepared for the pain I have witnessed. Every patient seems to have so many problems: an acute exacerbation of their emphysema or heart failure on top of their underlying diabetes and vascular disease and drug abuse compounded by a history of heart attack, stroke, and cancer. Either that, or they only have one, but it’s the one that is enough. And I don’t know how to process the experiences I have had even in the span of a week, especially now that I have been able to take somewhat more responsibility for admitting “my own” patients.
One patient, a known drug abuser, writhed in pain in his bed. He was begging for pain medication, but little could be done: so much drug use had dulled his responsiveness to opioids. And he had broken his “pain contract” with the outpatient pain clinic by seeking pain medications from more than one doctor, so he was no longer welcome there.
Down the hall, a man on the cusp between middle and old age sat reading a mystery novel while an IV delivered fluids into his arm to treat his dehydration. “I was in the hospital when my ‘friend’ died,” he said, slightly accenting the word, “and I guess I just stopped taking care of myself after that. We were together for almost forty years.”
One of my patients was a diagnostic challenge from the minute she came in from her nursing home for nausea and vomiting. She was sweetly demented, so she couldn’t say much about what had been going on, and she would tell different members of my team that it hurt at different times in different places. We kept getting excited every time we thought she had a new disease to add to her extensive medical history, hoping she was sick: if those really were enlarged ventricles on the CT scan of her brain and she had normal-pressure hydrocephalus, it meant we could do something for her. Otherwise, she was condemned to her dementia. She sat on a board of trustees only eight months ago, her brother said, and my eyes burned. We still don’t know how to treat her urinary tract infection.
The same patient left me kicking myself when the neurology team gave her the diagnosis of not normal-pressure hydrocephalus, but Parkinson’s disease, a long-standing interest of mine. How could I have missed the tremor in her hands, the rigidity of her limbs, and the classic expressionless face? Easily: I was fitting her symptoms to the diagnosis (NPH), not the other way around, and I never stopped to ask myself the question “what else could this be?” We started her on Sinemet to replace the dopamine her brain has run out of, and I know it’s probably all in my head, but I could swear that overnight she became more animated. Her eyes met mine when I said goodnight to her today, and I realized it was the first time she had smiled at me.
The hardest patient was a middle-aged man with end-stage liver failure and untreated AIDS. His body looked alien, humanoid but not like any other human body I had ever seen. His belly was enormous, perfectly round and stretched with ascites, the fluid seeping into his abdomen because it could not pass through his cirrhotic liver. His arms by contrast were stick-thin, all the muscle melted away. His legs were puffy with fluid, soft swelling over sticks. And his head was so shrunken and wasted I could hardly believe it could contain his skull. He looked out at us through wet brown eyes in an emotionless face, tense and quiet like a scared animal. His breathing became unstable this afternoon and he was moved to the ICU, sedated, and put on a ventilator. I guiltily felt a little better once he was sedated because he didn’t seem quite as much like a conscious soul trapped in a distorted body.
My last patient today was a middle-aged man with metastatic cancer. His cancer was originally diagnosed in another country a year ago. They gave him symptomatic treatment, and he felt better, so he thought he was better. This week he started having pain again, and his CT scan showed the mass had spread to three other organs. It was Stage 4 of 4, inoperable. Not years but months. His son grasped desperately at other explanations – it was an infection, it couldn’t be cancer because his father didn’t look sick enough. He asked me in his own words to help him understand the biology of cancer, seeking answers in mutated DNA bases and cells that lose the ability to stop spreading, eating through walls into other organs. On the first day we thought the patient spoke only Portuguese, so we relied on his adult children and the interpreter. On the second day I found out he speaks some Spanish, and from then on our communication has flowed through a wide-open channel, mixing our “fazers” and our “hacers” and cracking jokes and crying. It wasn’t the first time this year I have been so grateful for my Spanish. Exhausted from having no days off for two weeks, being on-call last night till midnight, finishing my work at home, and then coming in at 6:15 this morning and staying until 8, I still went in to say goodnight to him after I dropped off my note in his chart. And time slowed down for a while as I sat on the edge of his bed and we talked softly. He still feels shocked, and shakes his head at what he understands about what he is facing, but his voice was full of peace. In half-Spanish, half-Portuguese he spoke with deep gratitude of the love and compassion and professionalism he has experienced during his hospitalization. I wound up leaving at the end of this whirlwind day feeling that he had blessed me and my work, and I was uplifted, even though he was so far the patient I have seen who has gone most dramatically from health to illness. Obrigado, senhor.
