I am keeping a secret

Juliet Siena Okoroh, PRIME-HEq MS4 at UCSD SOM

AB is a 60-year-old male who came to the emergency department with a chief complaint of back and chest pain on defecation.

I walked into the room
At first glance at AB I felt something was wrong terribly wrong.

Please put AB on the monitor I told the nurse,
I then began to collect the history.

“What is going on, Sir? What brings you to the emergency department?” I asked. “I don’t know,” he said, “I rush to the restroom all the time to pee but nothing comes out. I have not had a bowel movement in 10 days and have no appetite.”

On further investigation, he also had lost 40-pounds unintentionally in the past month.

As I continued my examination, I quickly realized he was exhibiting Kussmaul respirations and a rapid heart rate although hemodynamically he was stable.

“Please let us transfer him to the front of the ED where we can monitor him more closely,” I said to his nurse, who agreed that AB was of higher acuity.

My attending physician evaluated Mr. AB and thought that his enlarged prostate symptoms would go away once we drain his bladder.

I said, “how do you explain a 40-pound weight loss in a man that has never had a colonoscopy, is heme-occult positive twice on my exam, tachycardic with an hemoglobin of 5 from 10 a month ago, tender on my examination of his abdomen?”
Let us obtain a CT scan of his chest/abdomen/pelvis.

My attending agreed that although AB might benefit from placement of a Foley catheter, parts of his story were more concerning.

We proceeded with the CT scan, which revealed metastatic disease to his liver which was interpreted as likely prostatic or colonic in origin.

I proceeded to admit AB to the hospital for further evaluation.

At this time, AB started to become anxious. “Can you tell me what they found on my CT scan”.

I responded, “we found something concerning on your liver, we don’t know exactly what it is however that is why we are admitting you to medicine for further evaluation. I apologize if we are not being timely in communicating with you about what is going on.”

He replied, “I understand, I am just curious that’s all.”

I continued to resuscitate and attempt to control his pain until I was at the end of my shift.
When I informed him that I was leaving, he said, “thank you, you saved me”

I responded, “You are in good hands. Don’t worry, they will take care of you upstairs”

As I walked to my car, I thought to myself, “Did I fully disclose the nature of his disease to him?”

Does he understand the extent of his disease?

Does he even know he has cancer?

Did I lie to AB? No

Did I completely disclose the extent of his disease? Unsure

Death & Dying

Elizabeth Griffiths, MS4 UCSD SOM

“Mr. Smith is becoming very interesting. Perhaps you should go meet him. Very nice man, so is his wife. Just get to know them. You can take over on Sunday when you come back.”

As a patient, you never want to be “interesting.” As a medical student, “interesting” sounds to me like no one knows what’s going on, so I probably won’t either. It also sounds like a lot of questions that I probably won’t know the answers to. But, I pressed on, asking my attending what his story was.

“73 year old man with known renal cancer. Scheduled for resection next week, but he presented to the ER with weakness. Found to have rising creatinine and rapidly rising LFTs. We did some imaging, and looks like he has an IVC thrombus. We’ll see if IR can do anything, but it’s Friday so nothing’s going to happen until Monday.”

Luckily, medical school had taught me something. Amazingly, the vocabulary all made sense, and if asked to tell a patient’s “story” I probably would have told it in much the same way.

So I went to meet Mr. Smith and his wife. One of the first things they want you to know in medical school is how to tell from the door whether someone looks “sick” or not. He did. Bright yellow, clammy, barely responsive. His wife did all the talking, and she was exactly as promised. Thrilled to interact with “the next generation,” happy to tell her husband’s medical history for probably the tenth or twentieth time. I told them that I would see them when I was back on Sunday and would be officially part of his care team starting then. In the meantime, my attending would continue to care for him.

On my day off, I thought about them a lot. Although no one had told me explicitly, I knew enough to know this was serious. You can’t last very long with liver failure, or with a clot blocking the flow of blood back to your heart. As much as I tried to read and prepare, I knew I needed to get in very early just to think about things again. That meant 5:30, instead of the usual 6:30. I went to bed and set my alarm.

That night, I dreamt that Mr. Smith had died overnight. It was all very vivid in my dream, but now all I remember is that he did. I woke up in a cold sweat, relieved to realize it was just a dream. But I knew I wouldn’t be going back to sleep. I got up in the pitch black and got ready to drive to the hospital.

Once there, I logged onto the computer, only to find he had been transferred to the ICU. I guess I could’ve slept an extra hour. I checked the records and saw that his blood pressures had been low overnight, and the usual measures weren’t helping. I began to round on my other patients, but my thoughts were with Mr. Smith and his wife.

As I finished, the other medical students were beginning to arrive. They wondered why I was there so early. “Just had a complicated patient, but I guess I got here early for nothing—he went to the ICU.” I got reassurances that my effort hadn’t been in vain.

“Oh it’s ok he’ll bounce back to you,” my friend said.

“Well I guess that’s better than the alternative,” I said, only half joking, and still bothered by my dream.

I kept refreshing the computer screen, and soon I got the dreaded message I had seen twice already this year:

“You are entering the record of a deceased patient.”

My heart stopped. Should I go offer my condolences to his wife? I figured she needed a bit of time to process, so I waited 20 minutes then went to the ICU. She was gone, but he wasn’t. I peered past the curtain, only to find him much the same as on Friday—bright yellow, lying still. I went back twice more but never found his wife.

I had just met Mr. Smith and his wife, barely spoken to him at all. Yet, I couldn’t shake my sorrow for at least a week. It permeated everything. Every patient encounter was touched by thoughts of them.

But, why? Eventually, most doctors come to wall these emotions off. To move on seamlessly to the next patient. Is this to be desired? In fact, I am more afraid of caring too little than caring too much. It seems to make me less human.

But, why? Death happens all of the time. As doctors, we just happen to observe it more often than most, especially in a society where death remains so hidden. We do not mourn everyday for the loss of countless unknown members of our species who must have died that day. Is it perhaps that we, as doctors, feel responsible for the death of our patients?

But, why? Death is inevitable. Yet we try to forestall it as long as possible. Are we at fault when we fail? What could I have done differently? Was I responsible? After all, I had promised to care for him starting on Sunday. At the same time, I had yet to start. If I had known more or been smarter, would the outcome have been different? If it wasn’t my fault, was it my attending’s? Or was it just inevitable? If so, should we have seen it coming earlier and better prepared his wife?

These were the questions that hung with me throughout the week, and perhaps they still do. But, mostly, I just wish I had been able to say goodbye.

The Honor is Mine

Written by the author, Maryam Soltani, PhD who is currently an MS4 at UCSD SOM. This piece is currently being slated for publication in the journal Academic Medicine.


Dr. Soltani’s original art work accompanying the piece.

 We were in a clinical conference in a hot stuffy room waiting for the next patient. The nurse wheeled him into the room; the sheer number of people crammed into such a small space took him aback. A massive left hemisphere stroke had left his right side paralyzed and his speech minimal. The physician began questioning the patient, who responded with garbled words and fragmented sentences that only his wife could translate. Over the years the two had developed their own form of communication. The patient’s frustration mounted. The crowd, his difficulty speaking, his paralysis – overwhelmed, the patient began to cry.

My resident said, “You should come with me, we need to admit a burn patient.” I walked into the room to discover an emaciated young man burned from head to toe, one patch of hair atop his head with gangrenous disfigured hands. He was lying in bed, laptop across his lap, playing video games. We introduced ourselves and conducted the exam.

 The next day, during morning rounds, it was decided that the patient would be an excellent teaching case. We rounded as a group in the patient’s room. Ten of us stood around the boy’s bed. We watched the resident examine him and turn around to discuss his findings. Out of the corner of my eye I noticed the patient looking down. A deep sadness encompassed his face. His spirit was shot. My heart ached. I wanted to hug him and say, “I’m sorry for putting your disease on display.” But, instead I stood there.

 Later, I returned to his room. He was preoccupied with his computer. I asked what he was looking at. He replied, “Legos.” His father promised to buy him a set as a reward for his courage. I said, “I love Legos! May I look?” I learned that the Legos of today are different from those of yesterday. You can build structures like the Gueggenheim. The patient turned to me and said that he used to build Legos all the time. But, now because of his hands he can’t put them together. So, he and his dad build them together. He excitedly asked his father to tell me about the time they built Big Ben. I saw a new vibrant happy young man. I became determined to find a set of Legos, so that he and his father could build a structure during his hospital stay. After two days of searching, I found a suitable set and returned to his room. With a twinkle in his eyes he said, “Thank you.”

 The image represents a child building Legos. It serves as a reminder that patients are opening themselves up and sharing their most private thoughts and concerns with us. As well as, allowing us to touch and examine them. It is an honor to be privy to this information. In a teaching hospital, the patients are our professors. Without them, we cannot become physicians. Each time I enter an exam room either alone or with a team, I need to remind myself of this and demonstrate mutual respect through my actions and demeanor. In the two cases above both patients had become overwhelmed by the crowd, medical jargon and public discussion of their disease. They had agreed to be examined by a group. But often, when we agree to things we are unaware of how we will feel once the experience begins. Perhaps an alternative could be to examine the patient with the team but discuss our findings outside of the patient’s room. This way the patient doesn’t have to hear his problems scrutinized and discussed by a team of strangers right there before his eyes.