I recently had the opportunity to work with a medical student while on call. I had received notice of a ward issue to see that sounded appropriate for his level. I asked him to go first and that I would join him shortly thereafter.
When I arrived, he briefed me on the problem at hand. When I asked what his thoughts were and what he wanted to do, he supplied me with a full and extensive workup for a simple case of pain.
At one in the morning, I reminded him that our job was to make sure nothing life threatening was happening, that we have done enough investigations to aid us in that cause, and to keep patients alive until the morning.
Without the backup, manpower or support, we were not in the best position to start investigating and treating everything fully, unless something truly worrisome was suspected.
Put simply, our job boils down to a half measure.
In a previous post I highlighted some positive feedback I received about my history taking. I received a lot of comments about sharing what I was doing. I think that history taking is a very individualized process. In all honesty, there is no right or wrong way to take a history. Each person’s style is a reflection of their thinking process, their knowledge base, and their comfort level and that naturally evolves over time.
Having said that, this is what I generally do now.
When you see patients with scabies or pink eye and you feel the creepy crawlies just itching under your fingers and eyes for the rest of the day.
…Embedding a Starbucks store right inside of a hospital is a genius.
These stores are make a killing of my wallet.
The challenge of my current schedule is that I must juggle my responsibilities between my core rotation and those of my clinic, to which I am obligated to spend time as well.
Sometimes it means missing out on some good learning opportunities due to conflicting schedules. Other times, the days off of one schedule coincide with the days on of another. I can be particularly hit hard if, like today, the day could have been spent sleeping post night shift.
Thankfully these scheduling anomalies are few and far between. However, when I think about how well established the challenges of balance are in residency, having an awareness of these issues can go a long way towards improving resident resilience.
In my last community survey, I asked how you assess your stress level. The responses demonstrated just how diversely and how uniquely each person’s stress manifests.
This time, I would like to ask a follow up question and allow everyone to share how they deal with stress.
Beyond identifying and dealing with the source of the stress, I personally take more time to spend with my wife. I try to sleep earlier to catch up on rest. I take a step back from studying at home and instead take up sketching and drawing again while listening to music to help me relax. At work, I try to meditate during my breaks.
How do you cope with stress? Share your tips with everyone.
One of the very first patients I had admitted was a 50-some year old father of three with a newly diagnosed colon cancer. His case read just like my father’s. Sudden changes in stool caliber. More bloating and fatigue. His wife started noticing that he looked thinner.
By the time I had approached him in the hustle and bustle of the emergency department, the news had already been broken by the emergency physician. “You have colon cancer,” he remarked on the bluntness of that interaction. It had left him in such shock that he had little to say for most of the day. I took my time to be thorough, answering questions, gathering the history, doing the physical - his moderately ascitic belly and an enlarged liver already hinted at something more sinister. Having already been subjected to one rectal exam, he asked if I needed to double check again. I politely declined to which he breathed a great relief.
I excused myself to review his CT scan, to get a better understanding of what was driving everything. There, on the black and white screen I saw a liver so large it seemed there would be no space for anything else in that belly. Pocked full of cysts and irregular tissue, it screamed only one conclusion: gross metastasis.
"A few more tests," I reassured him and then he would go home, to follow up with the oncologist for further management options. I explained that the cancer had spread and that the options will be limited. He digested the news silently, his eyes flickered across the floor as he concentrated. When his wife arrived, I made sure to break the news gently. She wept regardless.
By the time I had sent him home, his belly was flatter once again, having been drained of all of the malignant fluid. The oncologist was to follow up with him within a week’s time. The prognosis was guarded but we agreed that he will be fine for at least the week.
Or so we thought.
It was a surprise to me then that not one week later, I saw him again on call in the emergency department, this time looking worse. He was confused, agitated, and grim - his skin had turned yellow. I quickly texted my attending: “Encephalopathy. Icterus.” The response was immediate: “Shit.”
Because most of the patient’s liver had been replaced by metastatic tissue, his body could no longer bear the burden. The liver had started to fail and with that, his kidneys were beginning to shut down. He was quickly transferred to the ward.
We rediscussed code status with the family with the end drawing near and it was decided to change his care to palliative. We kept him comfortable until he died a few days later.
Precipitous multi-organ failure is uncommon to see in someone who is still very high functioning. We never would have expected him to decline so rapidly. It was a surprise to everyone that he could be here one week and gone the next. Given his disease, there would not have been much more we could do medically.
But there are always things we could have improved on. From delivering the diagnosis with care, to advocating for a private room in his final days, to addressing the psychosocial needs of the family. These are areas that we can strive to do better. At the end of the day, this patient was not his colon cancer, he was a person. With a wife and three children. A friend to many.
These were the pieces, in the torrent of changes that ensued on his second admission, that were lost.
"The patient died surrounded by his loved ones. We are grateful to have been involved in his care and offer our deepest condolences to his family and friends…End dictation."