Reflections from Intern Year (Part 2)

Emergency Medicine

There were many patient cases I encountered during my Emergency Medicine rotation in April that left an indelible, emotional mark on me, but I will highlight a couple. 

Preserving a Patient's Dignity

I developed quite a few frustrations with the field of Emergency Medicine during my month working in the emergency department (ED), including the lack of continuity of care, the stress of the high acuity of care, and importantly, having minimal time to spend with patients. The latter prevents you from taking a thorough history or performing in-depth physical examinations. It drove me insane. I'd gotten so used to being thorough on the general medicine services; it was such a shock to experience the rush of emergency medicine. I was forced to write brief, concise notes, rather than the thorough narratives and assessments & plans I was used to crafting on the inpatient side. 

It was one 3-11PM shift (that extended until 12:30AM) in the ED that made me realize how much I hated working in emergency medicine. It was the busiest shift I ever had: I didn't get the chance to eat, go to the bathroom the entire time, or even take a minute to myself. It was very stressful, what with trying to get a patient admitted to the general medicine service, discharging about three, dealing with an unstable patient with diabetic ketoacidosis, and seeing new ones. Things got very crazy. I could feel that my cortisol levels were elevated the entire time.

One patient, an 83-year-old African American woman, came in from her nursing facility after she was found to have a hemoglobin of 5.9 (normal hemoglobin for women: about 12-15.5g/dL). I had just come on to the shift when the decision was already made to send her back to the facility after she received a unit of blood. Unfortunately, after a repeat lab draw, her hemoglobin had actually dropped after getting a unit of blood to 5.5. I banged my computer mouse against the desk in frustration. There's no way we could send this poor woman back to the facility without ascertaining why her hemoglobin was dropping. I was simply told in sign-out (information about the patients for whom I assumed care) that she had a history of chronic anemia and intermittently required transfusions. But why? I wanted to push, but unsurprisingly, this is not information that the previous intern had, and it wasn't really their fault. Emergency medicine is not conducive to obtaining a comprehensive understanding of patients' narratives and medical problems. That's what the outpatient (or inpatient) setting is for. Not the ED. (Photo from here).

However, lack of information about why the patient had chronic anemia caused problems during my shift when I took over. I skimmed through the prior intern's incomplete note which stated that the patient had abdominal pain. No imaging was ordered, no rectal exam done, and I did not see any mention of stool history in the HPI (history of present illness). Goodness, I would have to do all of those things in order for the patient to be admitted to the hospital. The General Medicine team would definitely need this information.

Before entering the patient's room, I began to don my PPE (she was COVID+) and while doing so, I couldn't help but stare at her through the glass window of her room in the ED. She was entirely hunched over on her right side in bed, her glasses misaligned as a result of her head pressing into the bedrail. She was eating her chicken Parmesan meal with her left hand. A prior stroke robbed her of dexterity in her right hand to use the knife and fork on her plate, so she had to resort to grabbing the chicken with her left hand and stuffing it into her mouth. She made a complete mess of herself. The tomato sauce trickled down her left arm and was smeared all over her clothes and sheets.  

I wanted to cry when I saw this. I felt a lump in my throat and tears welling up in my eyes. I was astounded. I knew we had so much to do in the emergency room and it would take a few extra moments to don our PPE before entering the patient's room, but I was sure that we could all find 10 seconds to slow down and try to preserve our patients’ dignity by simply adjusting them in bed. Let's not have them make a complete mess of themselves while they are eating their meals. It took me just a couple of minutes to adjust this patient in bed and feed her dessert while at the same time tell her about our plan for her care. Why are we not slowing down to try to help our patients? 

I explained to her that I would need to examine her backside because we were concerned she may have been bleeding there. When I turned her, I saw that she was soaking wet and had dark black stool smeared all over her backside. Again, I wanted to cry. No one had changed this poor lady for the entire day. There was no need for me to do a rectal exam. She was obviously bleeding, and probably had an upper gastrointestinal bleed causing this dark tarry stool. I still could not believe that no one had thought to look at her bottom. I opened the door of the room and asked the nurse to help me clean the patient. The nurse must have been overwhelmed with other patients because she simply replied begrudgingly, "What supplies do you need?" Well, I thought, that wasn't what I was asking for, but okay. 

I cleaned the patient up as best as I could on my own, apologizing profusely the entire time. "Ma'am, I'm so sorry that no one was able to help you get cleaned up." All the while, this sweet woman continued to say, "It's quite alright, dear. It's alright." I shook my head furiously in silence, holding back tears. No, ma'am, I wanted to tell her, it's not alright. No one should have left you sitting in your own urine and stool for this long. There were multiple critically ill patients in the trauma bays that required more attention, but they were eventually stabilized. This patient was in the ED for several hours and no one at the facility or here in the ED was able (or willing?) to change her. Again, why are we not slowing down to try to help these people? I abhor that the field of Emergency Medicine oftentimes does not allow you to slow down and spend adequate time with a patient to establish rapport and thorough plans of care that they deserve.

 

The Air Mattress

During one overnight shift in the ED (11pm-7am), I saw a 50-year-old man who came in after a terrible bout of abdominal pain. He had just been discharged the day prior after a one-month stay in the hospital for multiple bowel resections and repairment of an inguinal hernia. He came back to the ED that morning because, since the night prior, he didn't have any furniture in his motel room to lie on, which would help facilitate his healing and recovery postop. He said that his father was going to buy him a recliner and deliver it to his motel, but when he got there, there was no recliner.  His bed was taken away due to hygienic concerns, per the motel owner and cleaning staff. All he had was a chair to sit on, but even that was broken. He woke up multiple times throughout the night. He began having sweats, chills, myalgias, and severely worsening abdominal pain. 

Fortunately, his lab work and imaging in the ED did not reveal anything concerning. His labs actually looked great. His physical exam also looked good: his postop scars were clean, there was no erythema, swelling, drainage, nothing. However, we didn't want to send him home if he didn't have anything there to sleep on. I spent a while talking to social work on the phone, but they were unfortunately unable to identify a way to get him an air mattress or any other furniture to hold him over until the arrival of the recliner that his father ordered. Apparently, the misunderstanding was that his father would buy the recliner while he (the patient) was in the hospital and deliver it to the patient's home, but none of that was done. The patient could not afford to purchase an air mattress for himself. 

I offered to give the patient's father a call to ask for assistance with the air mattress, but the patient adamantly refused. "I appreciate what you're trying to do, Doc," he said, "but that's not a good idea. You calling my pops could make things worse for me. He's an extremely stubborn Jehovah's witness, the chief of our family and household. If he says that the recliner won't get to my place until another few days, then that's that. He won't like it if he finds out I've sent some doctor to go meddling in his business." I asked if it might be better to call his mother instead. "Also not a good idea," he said apologetically. "He'll find out that you called her and become angry about me having someone go over his head to talk to her." 

"Okay," I said calmly, "what about your sister, or nieces and nephews who are living with your parents? Do you think one of them could run to Target or Walmart to get a $10-15 air mattress for you?" 

He shook his head no. "None of them have any money. They go to my pops when they need cash! And then he'll find out that I'm asking them for help when he's already told me that I need to just wait for the recliner to arrive."

This was getting ridiculous. I was trying to help this patient but he seemed to knock down every suggestion I had. I began to get angry with this father of his, but I tried to stay calm because I learned that their social situation was really tough. Earlier, the patient explained that his parents were taking care of his sister (who had "disabilities") and her children, who were previously abused by their father. I understood that there was a lot going on in that household, but I still found it frustrating that the patient was scared and insistent that I not call his father or anyone in the household. I simply wanted to ask if they could spare $10 to go to Walmart or Target and buy an air mattress for him. All in the name of his physical health! Family dynamics can get so complicated.

There was apparently no one else who could do this for him either. I explored a lot of other options with him. His family was basically out of the question, and he didn't really have any other family members around who were available to do this. In the motel, he was close to many of his neighbors. I asked if it would be possible to call one of them and ask if they might be willing to get him an air mattress. He shook his head no and said, "They don't have any money either. We're all paying extremely low rates to live in the motel. No one has any money.” I suddenly decided that I would go out to pick up the air mattress myself and bring it back to the ED for him. The patient expressed gratitude for my offering to do so.

Unfortunately, after I clearly communicated to the attending and nurse that I was going to go out and buy the air mattress for the patient, I was never told that the patient was being rushed out of the ED after my attending discharged him in the system. I made a plan with the nurse that we would keep him in a waiting or hallway area until I returned with the air mattress. When I learned after sign-out that the patient was gone, I grew annoyed with the nurse for not fighting for him to stay put somewhere nearby until I returned with the air mattress. 

"There's a chance he might still be out in triage or in the waiting area," the nurse said. I ran out to the waiting area but he was nowhere to be found. I tried calling the cell phone we had on file for him, but it turned out not to be his number. Someone else's voice and name were on the voicemail. The motel he mentioned had multiple locations, so I tried the one located closest to the hospital. No one by his name was staying there. I tried calling a couple of the other locations multiple times, but no one ever picked up. Perhaps because it was 12AM? I hung up the phone after trying the third location for the 4th time and sighed in frustration. I felt horrible. I felt like I really let this man down. I made a promise and I wasn't able to fulfill it for him. I worried that he would probably bounce back to the ED in the days he was waiting for the recliner to be delivered to him. 

I tried to make myself feel better by saying, well, I tried. I really did. But I still felt terrible. This poor patient was alone in what I imagined to be a dark, moldy motel room with a broken chair as his only furniture. He would almost certainly develop severe abdominal pain again after another night of immense discomfort. I was very sad that we couldn't solve the simple problem of getting this poor man an air mattress.

Intern Year Rewarding Experiences

Not all of intern year was stressful. In fact, it was mostly rewarding. Dare I say that I favor residency more than medical school? This is because I am deep in the trenches of patient care. This is why I became a doctor! To serve others, provide healing and comfort, and to fulfill God's purpose for my life. 

I'm grateful to have been selected as a recipient of the Duke NIH R38 CARiNG-StARR (Creating Alzheimer’s Disease and Related Dementias Researchers for the Next Generation–Stimulating Access to Research in Residency) grant at the midpoint of my intern year. I am studying the impact of adversity on epigenetic regulation in the development of Alzheimer’s Disease in African Americans.

It's been rewarding in itself to reflect on many other experiences and patient cases. I keep a notebook in my EverNote app that is dedicated to reflections throughout the year on difficult patient encounters, points of major growth in my training, teams that I worked well with (or didn't work well with), my growing passion for Alzheimer's, etc. It is at the end of these 12 months that I recognize more than ever how much I value the doctor-patient relationship. It is truly a privilege to serve patients in this profession.