Friday Reflection 49: The Patients of 12 Reisman
I did most of my inpatient general medicine on the 12th floor of the Reisman building at Beth Israel Hospital. Last spring, I returned to the Longwood Medical Area in Boston to give a talk. I had some extra time, so I asked a friend to bring me up to 12 Reisman. I thought returning to my old stomping ground would be a hoot. The visit made me realize that my residency was a bit more traumatic than I realized.
Walking around the ward, I remembered patients who once occupied about a third of the rooms. I remembered the names of many of these patients. I remembered the details of all of their hospitalizations. With almost 30 years of distance, I know what I learned from each of them.1
When a patient dies, residents need support
CT was an elderly woman who presented with fatigue and a chilling certainty that she was dying. Her medical history was only notable for a mastectomy for a rare type of breast cancer, cystosarcoma phyllodes. Our evaluation revealed recurrence of the cancer with extensive liver metastases.
We were puzzled because her burden of disease did not account for her rapidly deteriorating clinical state. Over the course of about a week, she developed hepatic encephalopathy, coagulopathy, and kidney failure. My resident and I despaired as we watched her condition worsen, with no idea of what we could do to help.
CT died about a week after admission.
When I presented CT’s case at our Firm Conference, I was met with disappointment that we had not “figured out the case.” I was roughly questioned about why I could not explain why the patient had died. I left the conference demoralized, sure that I had failed this patient — and that my incompetence had contributed to her death.
Residents are supervised much more closely today
RW was an elderly man admitted with dementia, falls, and incontinence. Our clinical assessment and imaging results were consistent with a diagnosis of normal pressure hydrocephalus. The neurology consultant recommended a lumbar infusion test to help make the diagnosis and to assess whether the patient would benefit from a ventricular shunt.
As the intern, it was my responsibility to perform this test. The neurology resident explained how to perform the test and how to graph the CNS pressure against the volume of normal saline infused into the CSF. He told me I could put the test off for a day or two until I was less busy and less tired.
Not all superpowers should be used
CW was an elderly man admitted because he was failing at home. He had been brought to the hospital after his neighbor heard him fall and called 911. When the EMTs arrived, they found him on the floor in a filthy, chaotic apartment.
CW had no family. He was competent to make decisions. He refused to go to a nursing home. My attending told me that the only way he was going to get off my service was if I convinced him to change his mind. I spent hours working on him. I learned that I can convince just about anyone of just about anything. I also learned that bullying someone into agreeing with you is not the right thing to do.
We only say that euthanasia is not an option
AS was a man in his 60s. He had lived with progressive interstitial lung disease for over a decade. He was admitted because the oxygen supply that was available to him at home could no longer maintain his oxygen saturation over 80%. The hope was that we could find something treatable. We could not. He adamantly refused discharge to anywhere other than home. When we decreased his oxygen to the level available at home, he was miserable.
After discussion with his family, he opted to decrease his oxygen to what would be available at home and take medications – opiates, benzodiazepines, and others – to allow him to tolerate the hypoxia so that he could be discharged. He was fully aware that with this plan, he might not live to leave the hospital. I spent a night with him adjusting the medications.
He died on 12 Reisman.
There is a right way to handle mistakes
TS was a 64-year-old woman admitted with unstable angina. She was started on intravenous heparin with a plan for PCI in the morning. After a heparin load, we started an infusion of 600 units/hour.
The nurse, however, did not run the IV tube through the pump so that over about an hour, the 25,000 units of heparin in the bag were infused. The nurse called me, and I called cardiology, hematology, and my attending to establish a plan. I explained the error to the patient, its potential consequences, and our plan. She, fortunately, did fine. She also thanked me for my care and honesty.
Once you’ve learned something, you can trust your gut
AA was a 78-year-old man with severe COPD admitted with an exacerbation. I don’t remember what it was about him – his appearance, his labs, his blood gas – but one night on call, I was sure he was heading for respiratory failure. I called the intensive care unit resident to evaluate him. The resident was hesitant to use up a “unit bed” for this patient, who seemed to be doing just fine on 12 Reisman. Fortunately – for all of us – the resident was a year behind me, had been my intern, and couldn’t very well refuse my request that he take AA to the ICU. He did make sure to needle me a bit, “Of course, I’ll take the patient if you, Dr. Cifu, don’t think you can manage him.”
About six hours later, AA was intubated for ventilatory failure.
This is what burnout looks like
I cared for AD for an entire month. She had progressive systemic sclerosis. During our month together, she suffered every complication of this terrible disease. Every day, there was another issue to deal with: malnutrition, wound care, gastrointestinal bleeding, hypoxia.
I was unprepared and ill-equipped to handle the issues. I felt like I was failing her. There were days when I was angry at her for the work she was creating for me. One evening, she was more unstable than usual when I went home. I remember coming to work the next morning, hoping she had been transferred to the ICU to give me a break.
At the end of the month, she was well enough to be transferred to a sub-acute care facility. I was bitter that I would be the one to discharge her and thus have to complete the summary of her prolonged hospitalization.
You might be miserable, but it is always worse to be the patient than the doctor
A couple of months after her discharge, I was in the emergency room admitting a patient when I learned that AD had come in earlier in the day. She had arrived in cardiac arrest and died. This was not a surprise; she and I had openly discussed her limited life expectancy while I was caring for her. What was a surprise was my reaction. I was overwhelmed by sadness. I was ashamed when I weighed my irritation against her suffering. I went to the men’s room, sat in a stall on a closed toilet, and cried (amazingly, for only the second and final time of my residency).
People with type I DM need insulin
Resident: What do you think is going on with PT, her bicarb is dropping.
Intern (me): I don’t know.
Resident: Have her sugars been OK?
Intern: Yes, they’ve been fine.
Resident: Have you had to adjust her insulin?
Intern: I stopped it a few days ago. Her sugars were fine. I was worried she’d get hypoglycemic so I d/c’d it.
Resident: You do know that people with IDDM don’t make insulin, right?
Intern: I guess I do now.
Cyclobenzaprine and sleep deprivation don’t mix
There was a satellite pharmacy on 12 Reisman. You got to be friendly with the pharmacist there. One day, post-call, I was hobbled by back spasms. (The call rooms were nice, but the mattresses were thin). I asked the pharmacist for a 10 mg cyclobenzaprine tablet. About an hour later, I think it was 3:00 PM, I needed to call a cab to get home as I couldn’t keep my eyes open. I slept for the next 16 hours.
I still don’t prescribe much cyclobenzaprine.
What currently passes as student mistreatment is laughable
One day, just as morning rounds were beginning, my pager sounded with an outside number. I called the number, and a woman picked up.
“Hi, I am Rose, I run the lot you park your car in. I am so glad I found you; this is the third hospital I called – I knew you are a doctor. You have to move your car. They’re repaving the lot today and if you don’t move it they’ll tow it.”2
I replied, “Thanks so much for calling. Why didn’t someone tell me sooner?”
“I put a note on your car 4 days ago.”
“Oh. I don’t use my car much. I mostly just trudge back and forth to the hospital.”
Faced with a panel of patients to see and manage, I turned to the only person I thought could help, my third-year medical student.
“Here is $20 and my apartment keys. Take a cab to my building and let yourself in. My car keys are on the table. The lot is right next door. Just park my car on the street, and I’ll move it when I get home.”
The student replied, “You’re sending me to move your car?”
I stared at him, apoplectic. “Um, yes. Do you think I should do it? I have patients to take care of. You’re welcome to have lunch in my apartment if you want. I am pretty sure there are some English muffins and ketchup in the fridge.”
Two of my most memorable 12 Reisman patients are not discussed here. Not only did I not need the floor to remember them, but I have already written about them on Sensible Medicine.
Just think how that sounded spoken with a spectacular Boston accent.
For the first eighteen months of Sensible Medicine, I posted a Friday Reflection every other week. At some point, I tapered off – I had written what I wanted to, which fit into this structure. Our readership has about doubled since I stopped posting these regularly. If you’re interested in reading them, I have them all saved up here.
The story about AS is not euthanasia, it was palliative care. You were not aiming for his death, you were aiming for discharge, which unfortunately was impossible. If you had sent him home with hospice without that trial, he would have suffered all night and died anyway and his family would have been traumatized. Instead you asked him his goal of care and he gave it to you, and you tried. I had a similar experience trying bipap on a lady who wanted to live but didn’t want intubation for a bad pneumonia. She didn’t make it. She wasn’t going to make it, she just couldn’t face it without trying one more thing.
When I was still working as a staff nurse and going to graduate school, I worked crazy hours and was assigned to patients that the regular staff didn't want. I would get angry because I felt abused but never opened up about it. I noticed something interesting. I would feel so guilty for not wanting the assignments that I would compensate by lavishing attention on the patients. They would then respond to this by loving me and it is hard to not love someone back. The patients I resented most became my favorites.