Inpatient Medicine

In the morning, we round on patients and monitor their progress. In the afternoon, we make phone calls to track down patient records, call primary care physician offices to schedule follow-up appointments, update other physicians on the progress of their patients, and on top of that try to deal with the myriad of social issues that inevitably arise with our patients. In the morning, we do what most people would imagine a doctor to do. In the afternoon, we do all the crucial busywork in an attempt to ensure some form of lasting continuity to whatever clinical improvement is made during a patient's stay at the hospital.

The term that keeps coming up in the hospital in reference to some of our patients is the word "babysitting." We make calls to their doctors when they should be doing it themselves. We repeatedly try to convince them to take their insulin when they complain they don't like getting shots to prevent one or more of the innumerable consequences of diabetes. For all the complexity that goes into learning about obscure diseases and the latest evidence based medicine, playing the social game is often just as difficult and a hundred times more draining.

It would be easy to blame all of this on patient lack of education, but the reality is that the messiness extends to all levels of society. Richer people may be more knowledgeable and compliant (and even this isn't a guarantee), but this does not always guarantee gratefulness or the ability to cope with dire circumstances. The mix of uncertainty, anger and denial will make the most educated person irrational--and all it takes an already stressed-out intern or jaded senior resident to turn a normally workable situation into an intolerable one.

It is this afternoon work that often drives many residents to do everything they can to avoid the social mess that is the modern health care system and pursue careers in outpatient specialties or more surgically oriented fellowships. After all, why should one go 200K in debt to subject him or herself to rude patients, patient who won't take their medications, chronic drug abusers who abuse the health care system as much as they abuse the drugs, and have to spend hours calling hospitals just to track down some test that was done 5 years ago that may not even end up being useful in the end? Why wouldn't you want to go into a field where you can dictate the patients you see and only have to deal with patients who actually want to see you?

Inpatient medicine is not merely Patient X has Disease Y that must be diagnosed by test Z and treated by drug 1 or Surgery 2.

No, it is much more often Patient X with disease Y will not take Drug Z for his condition Q which causes him to come into the hospital with complications A,B, and C leading to hospital stays that require expensive testing 1,2,3 that are ultimately paid by the taxpayer because Patient X is on Medicare or unemployment.

Refeeding Syndrome

It was the second time they went to go see him. It was the wing of the hospital furthest from the main building, the Forest, they liked to call it. He had a lot of problems. Cancer, fungus in his blood, cystic fibrosis, and probably a multitude of other opportunistic infections. The attending followed by the intern followed by the medical student. They were the infectious disease team consulted by the primary service to manage something.

"You look a little tired today," the attending said, dressed in the yellow isolation gown.

No response. He was known for not always being particularly responsive.

"Are you having trouble breathing?" He clearly was, but was still capable of speaking. He looked at them blankly and annoyed. The physician looked at him concerned.

The intern coming up along the bedside took a brief glance at the patient. With a quizzical look on his face he turned to his attending and remarked, " I think he might have refeeding syndrome. Sometimes after people haven't eaten for a while, their body has a hard time readjusting to oral intake creating increased carbon diox--"

"Listen to me," the emaciated 25 year had spoken. His hoarse, weak voice conveying the severity of his condition.

"The reason why I'm tired is because I can't sleep. Every night I have nurses that come in a readjust this and readjust that. I'm in pain. When I finally do fall asleep, I'm woken up again at 4:30 am so they can draw blood. Then for some reason, when the nurse comes in to get my blood, the other nurses think it's a good time to come in and take my blood pressure, take my temperature. Next thing I know some doctor is coming in at 6:00 am to ask me questions. Now it's bright out. Then when everyone finally leaves me alone you guys come along and ask me even more questions, see me tired, and think I have some refeeding syndrome. Now I don't claim to know as much as you doctors with all your knowledge and training, but what I do know is that if I could actually get some sleep here, I might not be so tired when you guys come around. What I do know is that I don't have no refeeding syndrome"

Silence blanketed the room. The attending turned to the intern, "I don't know why they have to draw blood at 4:30 in the morning. We'll try to stop by earlier in the morning so that he won't be interrupted as much."

And wishing the patient well, they turned around and left the room leaving the sick man to attempt sleep once more.

Hypernatremia w/altered mental status

He actually wasn't conscious when he first came in--of this we were aware. He came in last night, but that morning we met him as a team. Mouth perpetually wide open, hands wrapped in giant mittens to protect himself and others around him.

"Mister Griswolllld!" Our senior resident would yell out each morning shaking him by the shoulders. That morning he responded with unintelligible moans.

My intern whispered in my ear, "Hey Griswold. Where do you think you're gonna put a tree that big? Bend over and I'll show you!"

"You ever seen National Lampoon's Christmas?" he asked me.
"Parts of it, but never the whole thing"
"Alright. Your assignment for today is to watch some you tube clips of that movie so we have something to laugh about together."

Over the next week, Mr. Griswold would recover some form of responsiveness. Demented as hell, each morning he would be greeted and shaken. Eventually, the mittens came off when he was aware enough to stop scratching himself and pulling out his IVs. Then we noticed his hands.

"Hey, check out his lobster claw!"

His left hand sprouted three long and sinewy fingers and nothing more. The thumb, the index, and the bird.

"Watch out. Once he gets a hold of your arm, we'll have to chop it off cause you ain't getting it back!"

Those first few days we couldn't understand a word he said. Then, one morning, I went in with my senior for our daily shaking. He was already awake by the time we got there. Eyes open, he stared at us. We paused, startled at his consciousness. His ever gaping mouth slowly curling upwards, eyes fixed on her.
And then he uttered.

"IIII LUUUUV YOUUUUUU!"

"Awwwww" the inflection in her voice crescendoing as we left the room. "He said he loved me! Mr. Griswold!"

The last day I saw him we were planning him for discharge. Several steps from his room we smelled it. Clostridium Dificile. Shit. Literally.

"How you can tell it's C. Diff?" I asked.
"Just lift up his sheets and smell it."

And so he and his lobster claw were discharged from our service likely to relapse as soon as he settled into the nursing facility to which he was going, We had all come to see Mr. Griswold in a certain light. From unconscious, dehydrated admit to helpless, feces-ridden geriatric to lobster claw freak show, it's startling how little we actually knew about him.

"I loved Mr. Griswold," our senior mused.
"That's because he told you he loved you!" one of the interns replied.
"I know..."
"But he never seemed like the sort of guy that would have a history of being arrested several times for robberies."
"Oh, Mr. Griswold."

An Interesting Case

"Go meet Dr. Patel in clinic. She's seeing a patient of mine that I think would be good for learning. We're trying to decide whether she has acute or latent TB."

This is what he had been told, and like a good medical student one week into the medicine rotation, he scampered outside, through the snow, and up the stairs to the doors of the clinic.

"Dr. Patel's already in with the patient."

So down the hall and opening the door on his left he slid into a rather small room where the patient was seated in conversation with Dr. Patel.

Dr. Patel was gathering history. Have you any night sweats? fever? weight loss? hemoptysis? No, none of that, she said. She had had a hard life. Extensive medical history compounded by the common American co-morbidities. Any imaging? She thought she had some, but couldn't remember. On and on the history taking went. He picked up her medical records and glanced through them as the chatter continued.

Extensive psychiatric history. Well, given her history, who could blame her?

What did she do for a living again? Disability now, entrepreneur or something like that. They all failed though, her businesses. What were her businesses? He didn't ask.

She had been possibly been exposed to TB when she was a nursing student in the past.

Wait. What?

And then it clicked. He had seen this woman before. She did not recognize him. His memory stirred. Where?

The Ward.

She had wanted to kill herself. She was much more upset back then. He had tried to ask her about her history. She had snapped at him. Too many questions. Why did he want to know? She had left the ward and was supposed to go home but had disappeared according to police reports. That had been the last time he heard of her.

But here she was now. Sharing bits and pieces of a history not so unfamiliar. More psychiatric than medical in some ways, and more human than anything else.

Her most recent imaging turned out to be quite unremarkable. Disappointing from a medical standpoint. She would need further testing and there was no point in risking medication side effects when she was completely asymptomatic and without proper supportive imaging.

Walking back to the hospital, he thought about what she had told him before he left the room. She had told him that he would be a good doctor.

"You have a certain way about you, how you conduct yourself."

Really? Is that all there is to it? He had thought to himself. She didn't know him--just like he didn't really know her. The absurdity.

And then he remembered that this was supposed to be an interesting case. It had been, but not in the sense that he had expected--not medically or in a psychiatric dimension. He couldn't quite put his finger on how it was, and it bothered him. Another time, he would have to revisit it. Perhaps it would make sense then. In the meantime, another morning case presentation. 54 year old woman with a history of diabetes, hypertension, hyperlipidemia presenting with chest pain...