I am two months into my intern year and it has already been a whirlwind of an experience. So far, I completed three weeks of Neurology (Stroke, Gen Neuro, and Neuro consults), several Ambulatory (outpatient or ED) weeks, and 1 week of Gastroenterology consults.
I also just finished working 12 days straight on the General Pulmonology service. Hours were 7AM-7PM (or 5PM, but mostly 7PM). I alternated short (7am-5pm) and long (7am-7pm) call days with my co-intern. He had already worked 12 days straight before I arrived, so I was willing to do my own stretch of 12 days before getting a weekend off.
The Pulm service had me on an emotional rollercoaster. There were things that I loved and hated about my first inpatient Internal Medicine rotation as an intern. Overall though, the experience forced me to practice more independence and ownership over my patients' care. Two patients in particular had a great impact on me and pushed me to new heights in my independence and confidence as a fledgling physician.
To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of this encounter have been modified to protect the patients and their families.
Chest pain without a clear cause
We admitted to our General Pulm service a sweet 27-year-old woman with idiopathic (no clear cause) pulmonary hypertension (elevated pressures in the lungs) and a number of rheumatologic diseases (i.e. lupus, systemic sclerosis, etc).
She presented with chest pain that radiated to her upper back and had gotten worse over the past month. Her EKG showed sinus tachycardia (fast heart rate), and her D-dimer (a fragment produced during the degradation of a clot) was elevated. She was at high risk for a pulmonary embolism (blood clot in the lung), so we sent her off to get a CT angiogram. It was negative. We also sent her for a right heart catheterization to evaluate the pressures in the chambers of her heart. She also underwent a left heart catheterization when we learned that her troponin (cardiac enzyme) was elevated. The pressures in her heart were relatively stable from her prior catheterization during a previous hospitalization, and the left heart catheterization showed that her coronary arteries (which supply the heart) were completely normal. She also underwent an Echocardiography (ultrasound of the heart) that showed heart failure with preserved ejection fraction (seen on prior Echo during a recent hospitalization).
After all of these tests and some additional workup it was still unclear what exactly was causing her pain. Given her extensive rheumatologic history, it was likely of multifactorial etiology. It may have been partly due to costochondritis (inflammation of the muscles between the ribs), pericarditis (inflammation of the membrane surrounding the heart), or even esophagitis (given history of systemic sclerosis and patient's endorsement of some heartburn in the past). We decided to ask Rheumatology for their recommendations. We continued to treat our patient for her severe pain with oxycodone and other multimodal therapies, including an anti-inflammatory patch to put on the chest, a medication to prevent heartburn, and a lidocaine patch for the pain in her upper back.
While we continued to treat and find the cause for our patient's pain, other issues arose during her hospitalization, including recurrent bouts of supraventricular tachycardia (SVT), persistent nausea and vomiting (which she blamed on the veletri), and constipation (likely opioid-induced).
On the fifth day of her hospitalization, she went into SVT while using the bathroom. Her nurse sent me an urgent page to come quickly and evaluate. Her heart rate rose to the 190s. My co-intern and I rushed to her room. Both of the Pulmonology fellows were in clinic, so my co-intern called the attending while I talked to the patient and her mother to understand what was going on. The patient was on the toilet, crying in pain. She'd just received oxycodone an hour prior but was still experiencing significant chest pain, as well as a burning sensation in the joints of her fingers and toes. I encouraged her to perform vagal maneuvers to slow down her heart rate (i.e. blowing into a syringe and bearing down). A couple of nurses then helped her get from the bathroom back onto the bed for further evaluation.
We'd called for adenosine to be prepared and brought to the room in case it needed to be administered. While our attending was still on his way, another attending from the MICU (Medicine Intensive Care Unit) stepped in to see what was going on. One of the nurses quickly filled him in. He turned to me and my co-intern and asked us loudly if we'd ever given adenosine for SVT before. Dread filled me. I was terrified. No, I'd never administered adenosine before. I was also appalled that he would ask me this question in front of my patient's mother who was standing on the other side of the room nearby the window, but within earshot. I told the attending the truth, in front of my patient's mother.
I felt like a fool. For the past week I gained a sense of ownership over my patient's care like never before. Her primary concern of this hospitalization was the chest pain, but other issues arose that I began to manage independently. These included her persistent nausea and vomiting, constipation, poor appetite, and intermittent burning pains in the joints of the fingers and toes. I initiated therapies for all of the aforementioned at the consultation of my supervisors, of course. However, over the course of the week I did so less and less, making adjustments in her bowel regimen, nausea treatments, and analgesic therapies (for the burning sensation in the extremities) as appropriate. I worked hard to gain the confidence of both my patient and her mother. During my initial encounter with the mother, she was justifiably furious about her daughter's pain and the unclear answers to what could be causing it. I walked them through our thought process. I spent a lot of time with them during that week, updating them on the discussions we've had as a team and the anticipated next steps.
I felt confident that I'd built much rapport with the patient and her mother, as well as instilled confidence within them in the competency of our medical team and myself as a physician.
But I felt that that was stripped away with the one question asked by that attending about my ability to administer adenosine to my patient who was in SVT. I felt very embarrassed. "Great," I thought afterward. "Now the mother will wonder what in the world this incompetent woman who calls herself a doctor is even doing taking care of her daughter." I couldn't even bring myself to look at the mother.
Fortunately, our patient's heart rate went down to the 120s, and the EKG showed sinus tachycardia. She was given a one time dose of 1mg of IV dilaudid for her pain, and we immediately started her on a beta blocker (metoprolol) to slow down her fast heart rate. After putting in the orders for the additional IV dilaudid and metoprolol, I rushed back to my patient's room. Things had calmed down significantly. The crowd of nurses and techs that were gathered outside of her room had dispersed. My patient had just received the dilaudid, and her eyes were shut tightly in an attempt not to vomit into the grey emesis basin in her lap. Her mother was sitting quietly opposite her in a chair against the wall, staring at her daughter with furrowed eyebrows the entire time, concern filling her eyes.
I waited a few moments before speaking. I explained the nerve-wracking events from earlier, apologized for the scare, and expressed how relieved we were to know that she was okay. I reviewed the next steps of her hospitalization, and the main goals we were working on before discharging her home. Both had a lot of questions and I spent some time answering all of their concerns.
"Please don't hesitate to let us know if there is anything else we can do for you," I said to my patient and her mother after our chat.
My patient opened her eyes for the first time during this encounter and met my gaze as I rose to leave. "Thank you," she whispered.
Born with cystic fibrosis
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| Picture from here |
My patient presented to the emergency room with worsening shortness of breath, wheezing, and increased coughing over the past couple of weeks. He was not consistently compliant with some of his treatments (i.e. chest physiotherapy for airway clearance of the mucus buildup (see above picture)), and he was using substances such as cocaine. We started to treat him with antibiotics for the bacteria that were isolated on his sputum culture. The plan was to keep him in the hospital for the duration of the antibiotic therapy. Previously, he was discharged with a PICC (peripherally inserted central catheter), but had put heroin into the line, so for every admission after that he remained hospitalized until the antibiotic course was completed.
He taught me a lot about standing firm and showing confidence as a provider. He was hospitalized innumerable times in the past, and because of this he often tried to run the show by demanding certain changes or new additions to his management. One of the biggest challenges of this hospitalization was his anxiety. He would demand ativan a few times, but we were very strict about no benzodiazepines because of his current suboxone use (suboxone is used to treat opioid addiction). Concurrent use of suboxone and benzodiazepines can lead to adverse effects, including respiratory depression. We made it clear to him that we could not prescribe benzos.
On the day that his PICC line was placed, he requested ativan for the anxiety and fast heart rate he "knew he was gonna feel" during the PICC placement. Before I could respond, he said brusquely without taking his eyes off of the TV, "I already know what you're gonna say. I want to speak to Dr. K instead." I didn't argue. It wasn't worth the energy. If he demanded to speak with my attending then so be it. Unsurprisingly, my attending said that we could not give ativan (a discussion we'd already had both as a team and with the patient), and I was told to relay this to him. I headed back to the patient's room to tell him this, and just caught him as he was leaving his room to walk a few laps around the floor.
"Hey there!" I said, "I see you're about to go for a walk. I'll come back and we can have a chat afterwards."
"What is this about? You can tell me now," he said impatiently.
We were standing out in the hallway. Nurses bustled on by and other patients were walking around with their gowns hanging open and IV poles pulled alongside them. This was not at all the best place to tell him he couldn't get what he was requesting. I didn't want to risk dealing with an outburst, which was likely to happen given his volatile behavior.
"Let's go ahead and step into your room so we can talk. It'll be quieter in there," I told him.
"Is this about the ativan?" he demanded.
"Why don't we step into your room?" I suggested again.
"No, why can't we just talk about it here?" He spat. "What are you, scared?"
I was stunned that he would ask me such a question and I chuckled nervously. Instinctively, I quickly sized him up. He was about my height (5'8), of an average build, and his ambulation was somewhat limited by a lame left foot. He was wearing a boot brace on the foot. He had surgery done on the left ankle from an injury sometime ago.
I suppose I was being overly cautious about relaying this "bad news" out in the hallway, but at the same time I didn't want to cause an easily preventable disruption. No matter how gently I spoke to him, he would still become angry. I didn't realize I'd paused for so long until he started to walk away in frustration. As he limped away he turned around to shout at me, "You know what, I'm not gonna talk about this anymore. I know what my heart does when I get those PICCs put in. You can't tell me I don't need the ativan!"
He never got the ativan and he did just fine.
During the second week of his hospitalization, his nurse paged me to evaluate him for a new-onset tingling all over the body and a gripping, knot-like sensation in the chest that made it difficult to breathe. He was sitting up on the edge of the bed, anxiously rubbing his hands together. His systolic blood pressure was elevated to 179 but came back down to 150 by the end of the encounter. His other vitals were unremarkable. When I asked him to describe what he was feeling, the symptoms fit the description of a panic attack.
Once again, we could not give benzos (i.e. ativan) given his suboxone and opioid use history. We discussed seroquel, but patient refused, stating that the last time he took it he was "knocked out for 3 days straight". Hydroxyzine was not mentioned this time because of his prior extreme agitation at the suggestion (reports feeling suicidal on this medication). Finally, he said he did not wish to speak anymore because he was "gonna refuse everything" offered, but he still continued to discuss his personal issues outside of the hospital that were causing him great anxiety and stress. After talking for a bit about these concerns, he sat back in the bed, appeared calmer, more relaxed, and said with a smile, "I feel better now."
Thank you for reading!
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