Third Year Reflections

Internal Medicine

TIA observation.
Nursing home waiting list after PEG tube placement.
ACS rule out.

Within my first days on the VA wards I quickly learned that these are not considered “sexy” admissions. In fact, they are pretty run-of-the-mill. Maybe even – boring? As a newly-minted third year student I still had an eager excitement for every new case, but I could read between the lines when my resident said, “Sorry Andy, can you take this one today? We’ll get you a cool one next time.”

With those words, my expectations were preemptively set a little lower, my eager excitement tempered a little bit. But then I met the patients.

I met the patients. I sat in the room with them and listened. And they told me about themselves. Without the pressure of a half-dozen other patients to manage, I had the time to really hear them. And that’s when I learned that “TIA observation” doesn’t encompass a man’s life, his modest ranch outside of town, his herd of cattle that he and his son still tend to though they are now well into their 60’s and 70’s, and his fresh bread rolls that he bakes every morning.

I learned that “nursing home placement” was a man with a rich history in Dallas. A man who grew up brawling rough and tumble in the streets of Oak Cliff. A man who, in his twenties, got out of his 90-day jail sentence early with a combination of “good behavior” and a blood donation– then asked the pretty girl at the blood bank if she’d go with him to the movies.

I learned that “ACS rule out” was a delightful old African American gentleman. Surrounded by a loving wife, a daughter, grandchildren, and great-grandchildren, he enjoyed their company around his bedside late into the night. At first I was intimidated by his big family. But as we slipped into an easy conversation, and as I handed his toddling great-granddaughter a fascinating new toy (my penlight), I felt myself gaining the trust of the family. When he called me “a fine young man” at the end of the history and physical, I felt a swell of pride and satisfaction. I felt truly invested in taking care of him.

I am well aware that, as I write this, I am still a wide-eyed and fresh-faced third year medical student. I know that many of my attitudes and mindsets may change as my career advances and my experience grows. And without a doubt, I do hope to get exposure to a lot of cool cases throughout my medical training so I can learn how to manage the rare and the complex. But I also hope I will always remember that behind every “run-of-the-mill” case, there is a unique patient, an interesting story.

I hope I can always remember that there is no such thing as a boring patient.

Neurology

Ms. X

The first day of my neurology clerkship. My first brain death exam. An aneurysm in Ms. X's brain ruptured catastrophically last week and despite her doctors' and surgeons' best efforts, she remains comatose. The pressure inside her skull pounds with a deadly force and remains recalcitrant to all reduction attempts. Her brain has almost certainly been squeezed to death over the last few days and now we must confirm it.

I enter her room. She lies limp on the bed. Her mouth is wedged open by a breathing tube, lips and tongue motionless and awkwardly splayed around it. Her chest rises and falls, but it is clear that the breaths are blown in by a machine. No living lungs ever inhaled like that, so jerky and robotic.

I touch her foot– still warm. We call her and shout her name, dig our knuckles into her sternum and eyebrows, but there is not even the slightest flicker of response. We hold her eyelids open. The eyes that stare back are cold and lifeless. They respond neither to bright light nor touch nor icy water poured in the ear. We turn her head from side to side and they stay fixed straight ahead. When we let go, her eyelids stay eerily open. We suction her throat, but she has no gag or cough. With a grim finality, our team washes up and leaves the room.

Ms. X has told us enough. She will not be coming back.

It feels odd. I've known since starting medical school– with a sense of dread– that I would be involved in determining death. I've feared this moment, worried that I would not be able to handle it. But then it happens, and it almost doesn’t feel real. Maybe it is because I never knew her in life. Maybe because for me she has always been mute and unresponsive in an ICU bed. But in that moment, Ms. X's brain-dead body does not frighten me. I feel sorry that we can’t save her but I also felt a strange sense of relief. She is not suffering. Her organs will save the lives of others. And with her help, I learn a crucial aspect of the nature of medicine.

Ms. E

Ms. E suffered a ruptured brain aneurysm last week and she is doing remarkably well. She needs no breathing tube to sustain her. She wakes up, speaks to us, and sits in her chair to eat her meals. Her husband, daughter, and neighbors dutifully stand watch in shifts as she slowly recuperates from her brush with fate.

But something is not quite right with Ms. E. Although she opens her eyes and answers all my questions, when I pay attention to her perfectly fluent speech, I realize that the content is riddled with inaccuracies. As we check on her, she has a different story every day. Today we are in Hawaii, yesterday in Waco. Sometimes we are in a hospital, sometimes her home, many times in a place I am not familiar with. Our team members have alternately been doctors, chefs, or Lowe's home improvement staff.

And nearly every day she continues to ask us, “Are we going to check on the rats in the hall?”

Is Ms. E confused and disoriented after a traumatic bleed? Yes, but maybe there is something more. Given the ease and certainty with which she creates these elaborate stories, along with the location of the brain injury, she could be truly confabulating. When she tells us about a conversation she had with a visitor who was never there, is that reality for her? Where do these false stories come from? Do they seem as true to her as my world to me? Is she trying to mask feelings of confusion and disorientation or does she truly believe her imagined explanations?

I wonder about all these questions– how it feels to be a person with a frontal lobe injury–but I am left to speculate on my own time because, according to the neurologist, Ms. E is stable for discharge.

Ms. L

Ms. L does not have classical locked-in syndrome from a brainstem stroke, but when I first meet her, she is locked-in just the same. She is intubated in the ICU for severe, refractory, "brittle" myasthenia gravis. She cannot open her eyes, she cannot swallow her saliva, her head flops unrestrained on a completely flaccid neck. She cannot lift her arms, but her fingers still have strength. Remarkably, although she makes no facial or head movements at all, when I speak to her, she writes complete sentences on a pad by her hand.

Her handwriting is impeccable.

She is scared, paralyzed, and helpless in her own body, yet her mind is completely intact. What could that possibly feel like? To have perfect vision but be unable to open your eyes. To hear, feel, and smell the world but be unable to move or interact. How terrible and terrifying.

That first day, I hold open her eyelids so she can see me. Her eyes seem to have an expression of gratitude. She tells me the breathing tube feels like it is choking her. I ask the nurse to let her have some of her sedative. Sleep soon comes to relieve her from her cruel imprisonment. It is the one act of kindness in my power that day.

Slowly but surely, with daily blood cleansing treatments, Ms. L begins to improve. The change is so gradual it's sometimes frustrating, but her strength unmistakably begins to return. She starts to gives me a thumbs-up when I see her in the morning. Her eyes can finally start looking up and down. She begins to hold her eyelids open without assistance and her neck muscles allow her to start shaking her head. One afternoon I find her sitting up in bed, head held high, reading the newspaper with her glasses on.

The last day of my rotation is here and it's finally time to take the breathing tube out of Ms. L's windpipe. We're all very excited with her progress.

"Do you know how much money we had to pay her to get better on the last day of your rotation?” my attending jokes.
As I enter the room, her family members are all smiles.

"Hello," Ms. L says.

"Ms. L!" I start. "This is the first time I've heard your voice!"

"Yes," she replies. "I have a voice. I have a voice."

Surgery

Heading into the final rotation of my third year, I hoped that I would be able to manage the workload of my surgery clerkship– at least better than I might at the beginning of the year. And sure enough, my experience with the hospital, electronic medical record system, and early morning rounds was tremendously useful. But nothing could really have prepared me for the crush of terribly sick patients that I encountered on a daily basis during two months of surgery.

I have seen more pain, dismemberment, and poor prognoses during this rotation than on any other thus far. Some of the patients will be seared into my memory for quite some time: the 20 year-old girl who was ejected from her car during a highway speed crash after a night out and died the night of her birthday, the surgeons beating her heart in their hands again and again.

The young, homeless paraplegic man who arrived in the ER with gaping sacral decubitus ulcers teeming with maggots.

The cachectic corpse-like old man whose brother insisted we go to the operating room despite obvious massive bowel ischemia– on opening the abdomen, dark patchy purple intestines poured out; he died a few short hours later.

The young woman with 95% total body surface area burns after somebody had doused her with gasoline and lit her on fire.

More than the hours, the workload, or the lack of sleep, it was the sheer magnitude of human suffering that fills the halls of Parkland Hospital that was most challenging for me during this clerkship.


Faced with this deluge of misery, it is no wonder to me that young physicians-in-training often emotionally detach from the plight of their patients. While most of the patient-physician encounters I witnessed were medically very professional, I was struck by how easily the residents could move from one life-changing illness to another without a break in their stride. Surgeries, rounds, wound care, and floor work dominated our days - hand-holding and listening to feelings did not. This armor is no doubt a necessary survival technique in order to carry on and care for the many patients in need. By the end of this rotation, I saw how I too could easily lose sympathy for patients when faced with the workload of surgery residents.


One of the issues I worried about even before entering medical school was that the experience would change me– that I would become callous to suffering or cynical about life. I had read and heard in many places that so many empathetic young students emerge from their training grumpy and mean. More and more though, I am beginning to see that one’s attitude towards patients (like so many things in life) is an active choice, not simply something that happens. The balance between paralyzing empathy and emotional detachment is a tricky one when it comes to caring for the ill, and one that requires constant conscientiousness. While it may be easy to criticize trainees for their loss of idealism in medicine, it is a much more difficult thing to actually go through the harrowing growth process and continue to retain the appropriate dignity for people in what is oftentimes the most undignified of situations.

Ultimately, within the midst of all the chaos and pain of the hospital, I did consistently find examples of truly honest doctoring by both residents and attendings. I saw doctors who were patient, spoke kindly, and thought carefully about the best medical therapies they had to offer– even when faced with poor options and having worked non-stop all day and night. I saw lives dramatically saved and suffering eased. And at the end of the day, I saw doctors doing their job. I still have a way to go, but I know that with the right attitude and the right role models, I too will soon be able to call myself a competent, caring physician.

Author

Andy Yu will be starting his Pediatric residency training this summer at Children's Medical Center/UT Southwestern in Dallas, Texas. In composing his MS3 end-of-clerkship essays, Andy appreciated the therapeutic effects of reflective writing, especially in the setting of his first true encounters with illness. He plans to continue documenting his experiences in medical learning for years to come.

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