From Coast to Coast - Addiction, Research, and Alzheimer's

San Diego, CA

Third year of residency has started off with a bang. I spent a few days in July at a research meeting in Minneapolis and another few days in DC for the REACH orientation program (Recognizing and Eliminating disparities in Addiction through Culturally informed Healthcare). In early August, I was fortunate to travel to San Diego for the Alzheimer's Association International Conference. To the right is the view from my hotel room. Isn't this unreal? 

Minneapolis

I flew to Minneapolis in early July for the Diversifying CNS Workshop, a program that is committed to retaining diverse investigators (including underrepresented minorities) in neuroscience research. It was nice not to experience the chilling winter weather that the Midwest is known for. In July, the sun was out, it was 70s, and the breeze felt amazing on my face (unlike in North Carolina where it is currently 90s and very sticky and humid). It was a refreshing time learning about the neuroscience research that the other participants (post-docs, early-stage investigators, and graduate students) are carrying out in their careers. The support and advice we offered to each other, as well as the community-building activities, were energizing. Outside of our 2-day meeting, I'm grateful for the chance to meet with a friend from high school who is currently a medical student at the University of Minnesota. We grabbed food from French Meadow, a nice, organic, cafe and bakery in Minneapolis. I am not a vegetarian, but the veggie burger from this place was the absolute bomb. On another night, I ordered takeout from Tea House, a popular Chinese restaurant nearby the Graduate Hotel. That Chinese food was also pretty bomb.

DC

After the 2-day stay in Minneapolis, I returned to NC for my afternoon Neurology clinic, then drove to DC the following morning to attend the orientation for REACH. REACH is an Addiction program that strives to build the capacity of the workforce to better care for racial and ethnic minoritized patients with substance use disorders. REACH stands for Recognizing and Eliminating Disparities in Addiction through Culturally Informed Healthcare. 

This orientation was much more broadly applicable to my career and personal life than I realized. Our discussion about the social determinants of mental health, in particular, completely transformed how I should be thinking about the broader policies and structures that contributed significantly to the inequities and disparities we are seeing in healthcare. It was incredible to hear Dr. Ruth Shim (from UC Davis, who actually gave one of the Duke Psych Grand Rounds) discuss how it is actually more important for us to consider the social determinants of health and the policies and structures that have affected our patients. 

San Diego - Alzheimer's Association International Conference

Finally, I left for San Diego very early the morning after a two-week stint on the consults service at the end of July. Highlights include the view from my hotel room (see photo above), networking, meeting people from all over the world (there were >7,000 registrants for the conference), learning about the latest research in the field of Alzheimer's, and the amazing jerk chicken I ordered from the Rock Steady Jamaican Restaurant. Am I crazy to not have known that there are Jamaicans in San Diego?! They make up a small part of the population, though. 

It was wonderful also meeting with a friend from medical school who is currently in residency at UC San Diego. We went to Oscar's Mexican Seafood, and the shrimp tacos were to die for. Ice cream at the Baked Bear also comes highly recommended.

JAR Year Part 2

I cannot believe it is already the end of my second year of residency. Where has the time gone? Stepping into my new role as a Neurology resident for the first time in July 2021 was overwhelming. Now, I can't believe I can say that I am able to go to a stroke code with a level head and clear mind, ready to help the primary team choose the next best course of action for the patient.

Below is a picture of many residents, fellows, and faculty in the Department of Neurology at Duke University Medical Center. (This is not the entire department.) It was such a privilege to stand next to these folks and celebrate our community that day (June 2022).

Duke Neurology
June 2022 

I'd like to share a couple of patient encounters this year that have left an indelible mark on me (many did, but these stood out a bit more).

To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families.

What Did You Just Say?

One day in Neurology clinic, I had a follow-up appointment with a patient for tremor. He was 80 years old and from rural North Carolina (about a two-hour drive away). Let's call him Mr. S. He always brought his daughter to the visits.

"How are you doing today, Mr. S?" I greeted the patient and his daughter warmly upon entering the room. Ie made my way over to the chair with the computer and we proceeded with our visit. I was glad to hear that he was doing well on the topiramate (an anti-seizure medication that is considered second or third-line for essential tremor). Initially, he tried propranolol, but he did not tolerate it due to gastrointestinal upset. Primidone was not tried because it could interfere with another medication he was taking for long-term immunosuppression after a transplant.

Mr. S was pleasant, though oftentimes he went on tangents about random topics, such as the part-time work he was still doing in construction and his family (he always bragged about his 18 grandchildren. Yes, 18). He could also be quite interruptive whenever I spoke (but not as interruptive of our male supervising attendings, might I add), so today I tried hard to keep us on track. 

Just as we wrapped up our chat and I began to stand to do the neurological exam, Mr. S started another story, this time about his previous neurologist. He spoke with disdain about this physician, who practiced closer to Mr. S's hometown two hours away. "The propranolol he gave me helped at first, but it really made me sick," Mr. S said. I wasn't quite sure why we were rehashing something that was already established several visits ago, but I quietly listened anyway. "You know, I don't like that neurologist. He was dark-skinned, from India."

Whoa. All I could do was stare at Mr. S. A million thoughts ran through my mind:

Is he even hearing what he's saying?! And to ME, no less?

If he doesn't like this other physician who is dark-skinned, then what is he trying to say to me about me?

How is this at all relevant to the visit?

Should I just cut him off and get back to the exam?

The neurologist might not be from India, maybe he's from another South Asian country, the Middle East, or even somewhere in Europe or Africa. Why the automatic assumption that this "dark-skinned" physician with "Indian" features is from India?

The latter thought was, in the grand scheme of things, an irrelevant response to Mr. S's completely inappropriate comment. I decided to counter with, "But I'm dark-skinned, Mr. S." Then I stared at him while resting my chin in my hand to see how he would respond to that. I just wanted him to have some semblance of self-awareness about the words that were coming out of his mouth.

Mr. S stumbled a little. "No, I know you're dark-skinned. But that's different. He's a foreigner, from Iraq or India or something like that. He was born out there. You're from here." 

I noticed that the daughter was completely silent this entire time. I couldn't help but wonder what she was thinking. Was she embarrassed about her father's behavior? 

I didn't have time for this nonsense. We were getting too far off track and I needed to see my next patient. I immediately changed the subject and brought us back to the issue at hand. When he returned to the clinic months later, we carried on as if he'd never made any racist comments and revealed his true self. I shared the story with a few of my colleagues and my family. My colleagues were astonished, and my family found it humorous. "Well, you're in the South, Deb," they told me. 

When I told my mother the story, her immediate question was, "Did your patient have any mental or cognitive issues?" In fact, he did not. All of his cognitive faculties were intact, but given his overt racist ideology, I'd argue that my mother wasn't too far off to wonder if he had some issues with his mind. Racism is a reflection of moral failure, likely lack of education and enriching exposure to cultural diversity throughout one's life, and quite frankly, utter stupidity. The foundation of racism is the belief that a group of people are inferior to another simply because they have more melanin in their skin.... and look "different". That's really what it comes down to. And that is foolishness.

It is easy for us to recognize the faults in our patients who might come to us with this ideology, but it's just as important for us to recognize any biases within ourselves. I'm personally passionate about addressing health disparities among groups that have experienced socioeconomic disadvantages historically, but I'm far from perfect myself. It should be our goal as providers to practice constant self-reflection and strive to recognize any ounce of bias within ourselves that can potentially impede our interactions with our patients or the care we're providing for them.

"The only way to prevent unconscious biases from influencing our actions is to scrutinize our social behaviors, even in situations when we believe ourselves to be above discrimination." - Donald Barr, MD, PhD, Health Disparities in the U.S. (2019).

Why So Stubborn?

Earlier this spring 2022, I saw a 70-year-old male patient in the Neurology clinic at the VA Hospital with one of our well-known attendings in the Department. When asked why he presented to our clinic for the first time, his response was a shrug and a "I don't know. It should be in the records." (I can't tell you how often we hear this, especially at the VA). Review of his medical records revealed that his primary care physician was concerned about memory and walking issues. The description in the note was scarce, but it did mention that he had a heavy drinking history. There was no other contact information in the chart. No one was listed as an emergency contact. The patient, who we will call Mr. M, came to the clinic visit alone. Whenever a patient is coming in with "memory issues", he/she should always come with a loved one who can provide collateral information.

I learned that Mr. M lived alone, was not married, had no children, did not have many friends, and did not speak to his family. Unfortunately, trying to speak with Mr. M about the memory issues was like a painful climb uphill. I was not getting anywhere, and the information he provided was not helpful.

I started off open-ended. "Mr. M, tell me about these memory problems you have been having."

"My memory is fine," he shrugged.

Great start.

I thought that offering some examples might be useful. "Have you been having any difficulty remembering things like conversations from earlier in the day, tasks that you need to complete throughout the day, or perhaps words that used to come quickly to your mind when speaking with others?"

"No."

"Have your family or friends ever expressed any concern about your memory?"

"I don't have no friends. And I don't talk to my family. My sister owes me $5,000."

"Do you have a support system around here?" I asked.

"I used to have friends. They would always just call me "crazy" whenever we went out to drink. So I don't hang out with them no more."

I waited for him to offer more information but none came. "What do you mean by 'crazy', Mr. M?" 

He shrugged. "I don't know, they just called me crazy."

Dear Lord. I began to feel like I was being punished. Again, I provided some options. "Did they call you crazy because of something you did? Was it the way you were dressed? Your speech? Did you drink too much? Why were they calling you crazy?"

"It wasn't because I drank too much. I don't know why."

"Can you think of anything at all, Mr. M?" I felt myself trying to control my annoyed tone. This was probably the best I was going to get for collateral information.

He paused. "Well, they thought I stumbled on my feet a lot, and that I'd say things that don't make sense."

OK maybe this was going somewhere. I decided to address the stumbling first. "Have you noticed that you've been stumbling on your feet too?"

Mr. M proceeded to describe, with more painful prompting, a picture of syncopal episodes; in his mind, however, the "blacking out" and frequent falling were due to vertigo. (Vertigo, by definition, refers to a sensation of false motion, which he did not at all describe). He refused to use a cane or any assistive walking device because it "made him feel old". (You are 70 years old, Mr. M, I wanted to say). “I just don’t have to fall backward and I’ll be good."

As for "saying things that don't make sense", he explained that months ago, his friends told him he'd forget conversations and had word-finding difficulties from time to time. Throughout all of this, he continued to dismiss his friends' concerns and adamantly state that his memory was fine. I couldn't help but wonder if a denial of the memory problems led him to cut off his friends.

He denied having any problems with his activities of daily living (bathing, dressing, toileting, eating) or instrumental activities of daily living (managing finances and medications, going grocery shopping, driving, etc). Truthfully, I didn't believe some of this because I could already tell that the information he provided wasn't very reliable. He reported drinking only 2 beers/day and 4 on the weekends (also didn't quite believe this given a significantly documented heavy drinking history). He scored a 16/30 on the Montreal Cognitive Assessment (MoCA), our most commonly used neurocognitive test in the Neurology clinic. 16/30 is a poor score, but the MoCA has cultural, language, and educational biases. His highest level of education was high school.

My attending (who has practiced neurology for over 40 years) and I spent a long time trying to convince Mr. M to speak with our Social Worker and see the cardiologists for his episodes of loss of consciousness that were consistent with syncope. He spent 20 minutes alone insisting to my attending (again, who has practiced neurology for over 40 years) that his "blackout" episodes were due to vertigo, not syncope. I grew frustrated after we spent a long time (and multiple times) trying to patiently explain the difference to him. This also wasn't the primary reason for the visit in the first place. 

While writing the note after the visit, I couldn't help but feel discouraged. My initial frustration turned into sadness. We diagnosed the patient with mild cognitive impairment and insisted that he speak with our Social Worker for resources (including an assistive device to help protect against the falls, and get plugged in to a VA support program for individuals with cognitive impairment. We felt particularly strongly about getting him connected to these resources because he had no family or friends around. I was discouraged because he was refusing help (which made me wonder why he even came to the appointment in the first place), and because there was a possibility in the near future he'd suffer another syncopal episode that could result in a massive head injury. Or continue to decline in his cognition, impairing his ability to even take care of himself and complete activities of daily living.

How do you help someone who doesn't want to be helped? This was a particularly challenging case because it hit close to home (I have had many personal experiences with struggling to help loved ones who do not wish to be helped), but I also found it galvanizing to strive to advocate for patients (especially those that have historically suffered from many social disadvantages) even when they cannot or refuse to demand for themselves the things they need to be in good health.

Neurology Junior Assistant Resident (JAR) Year Part 1

I am halfway through my second year of residency (first year of focused Neurology training), and I am both exhausted and thrilled to be doing what I love - saving people's brains (and spinal cords too, sometimes).

The learning curve as a JAR (Junior Assistant Resident) is much steeper. Not to mention the added responsibilities we are tasked with, including teaching interns and medical students, running to stroke codes, providing guidance to medical teams that have requested our expert advice on their patients, etc. 

As a PGY-2, I complete inpatient rotations such as Stroke, General Neurology, the Neurology consult service, the Neuroscience Intensive Care Unit, and outpatient rotations in neuroimmunology, headache, neurodegenerative (i.e. movement, memory disorders), and at the Durham VA Hospital. We also have a few weeks of elective time which we can use to complete rotations in certain sub-specialties and related areas such as neuro-ophthalmology, neuro-otology, sleep medicine, neuroradiology, and research. 

2021 was overall a tough year, what with the demands of residency and the stress of the persistent COVID pandemic, but truthfully, I am so grateful for the challenging experiences because they have made me into an even stronger and more mature individual. I am also grateful for my achievements this year, which would not have been possible without the mentorship of incredible faculty. This includes the Duke R38 Research Grant to study some of the mechanisms underlying racial disparities in Alzheimer's Disease. I appreciate the opportunity to share more about my research interests on the Duke website through a Resident Spotlight interview. I've grown more passionate about cognitive impairment over the last few years and decided to take up volunteering as a Community Educator through the Alzheimer's Association. 

I'm tired but these activities are fulfilling and honestly, they keep me going. Dr. Siddhartha Muckherjee's 2018 article in the NY Times entitled "For Doctors, Delving Deeper as a Way to Avoid Burnout" encapsulates how much the extracurricular pursuits we're passionate about can keep us engaged in our medical careers. Throughout the article, in discussing his and a few of his former medical school classmates' research pursuits, he states, "We survived, I think, by deepening our commitments to research. We tried to increase our mastery within peculiar medical niches. And powerful, autonomous interests kept us going." Importantly, however, the support of my family, friends, co-residents, and therapist has been critical for my mental health and overall survival in residency.

I cannot forget the sheer exhaustion I have experienced just over the past few months, especially during my time rotating through the Neurology consult service. I remember that one of my busiest nights was in early August 2021, a couple of months into my first year as a Neurology resident (PGY-2). Things got so crazy that I didn’t get the chance to eat for the entire night and I barely drank any water. (Truthfully, I could and should have taken a break but unwisely chose to power through). I only ate a raspberry cheesecake cookie from the Subway downstairs nearby our cafeteria. I’m not sure I even went to the bathroom. It was a busy night. We had about 5 stroke codes and 6 consults in 12 hours. I guess it could’ve been worse, but it was still bad.

By the way, just for reference, one consult alone takes a lot of time - it involves chart review, seeing the patient to chat with them about their illness and to do a physicial exam (or even contacting family members if the patient is not able to explain what brought them to the hospital), relaying recommendations to the primary team (main medical team that is taking care of the patient), assisting with the disposition (where the patient will end up, i.e. home, admission to the hospital, etc), and writing the consult note, which consists of documentation of the HPI (history of present illness: the patient's narrative), physical exam, and assessment and plan. All of this can take quite some time.

Regardless, when I am woken up out of sleep and have to drag myself out of the cozy, dark, and warm on-call room to see that 3AM seizure consult in the emergency room, I remind myself why I chose this career in the first place.... and all becomes right in the world once more. It's truly a privilege to see patients who are suffering from neurologic emergencies and conditions like stroke, seizure, acute demyelinating diseases in the brain or spinal cord, etc, and to be able to get them the treatment they need (i.e. thrombectomy to remove the clot that's causing the stroke, anti-seizure medication, steroids for the demyelinating diseases such as multiple sclerosis, etc).

Localization in neurology is also pretty cool (and scary, depending on how you look at it). Believe it or not, one very tiny stroke in a small part of the brain (i.e. brainstem) can cause multiple tremendously debilitating symptoms, such as eye problems, weakness, speech changes, sensory deficits, and/or other symptoms. 

Stroke is certainly the biggest neurologic issue that we deal with and are consulted for in the hospital. What's the biggest risk factor for stroke? High blood pressure. Other risk factors include high cholesterol, diabetes, obesity, obstructive sleep apnea, heart disease, tobacco use, etc. We have to get our blood pressure under control! Let's also get that cholesterol under control by modifying what we consume on a regular basis. Let's try to be more active in our day-to-day as well. And the diabetes? We need to keep that in check too. If you snore and are overweight, you might consider asking your doctor to order a sleep study for you (keep in mind though that sleep apnea can also occur in people who are not overweight). If you have sleep apnea, that needs to be treated. Stop smoking! Go to your follow-up doctor visits. Take your medications. It's simple! An estimated 80% of strokes are preventable. Can you believe that?

Anyway, I'll get off my soapbox now. I will try to post another entry sometime this spring highlighting some interesting cases.

Thanks for reading! :)

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.

Reflections from Intern Year (Part 1)

I am at the end of my intern year of residency. I completed a year of Internal Medicine, which is required for Neurology residency training. I will then begin my Neurology focused training in a couple of weeks, which will last for 3 years.

First day of Intern Year (Orientation)
June 25, 2020

This past year was arguably one of the most challenging and rewarding times of my life. I knew that internship would be difficult, but I never imagined that my experiences would leave me feeling all of the following: humbled, beaten down, furious, shocked, depressed, exhausted, laughing so hard I was clutching my stomach, overwhelmed, stressed out beyond belief, and ultimately, even more passionate about becoming a competent, empathetic physician for patients.

It has been a whirlwind. A surge of random memories is sweeping over me (many negative I realize haha, but I have more positives to share later): getting cursed out after my 28-hour call by a frustrated patient at the VA who demanded more information about his upcoming orthopedic surgery. Feeling so exhausted after working a non-stop 12-hour overnight shift in the Emergency Department that I found myself walking around the parking garage for a good while because I'd forgotten where I parked (I made it home safely). Getting swung at by an angry patient during my night shift on the Cardiology service because the day team had forgotten to re-order his pain medications. Witnessing the "n" word get thrown around by a drunk, older white woman in the ED. Also in the ED, caring for an acutely psychotic patient who used to lead a drug trafficking ring. In clinic, seeing an Arabic-speaking woman whose agitated son demanded that I prescribe a 3-month supply of narcotics for his opioid-naive mother without any clear indication for them. 

If you haven't already guessed, residency can be quite an entertaining time. The aforementioned experiences taught me the importance of maintaining a calm composure in high-stress situations. The stories certainly don't end there. And they're not all negative either! It has been amazing working with remarkable, selfless co-interns and residents at Duke. I also can't express enough how wonderfully supportive and encouraging the leadership has been (program directors, Chief residents, other faculty). I have been pushed to learn and grow in ways that I truly didn't think were possible. I deeply value the relationships I've been able to build with my patients in both the inpatient and outpatient settings. I am so grateful to one of my senior residents who showered me with affirmation early on in my intern year, generously sharing that I had one of the best bedside manners he had ever seen by any provider. I embraced opportunities to mentor both medical and PA (physician assistant) students, all of whom were valuable additions to the medical team.

I'd like to share a few stories and highlights from my intern year in this entry. For the sake of organization, I will break it up into challenging experiences then I'll end briefly with the rewarding parts of my training thus far. 

To ensure HIPAA compliance, personally identifying information has been omitted/changed and certain details of these encounters have been modified to protect the patients and their families.

Intern Year Challenges

Imposter Syndrome: Being at the Bottom of the Trainee Totem Pole

First-year residents (interns) are fledgling physicians who just finished medical school. We are on a steep learning curve throughout the year. Sometimes I found myself wondering: what in the world would I do if I didn't have [insert name of upper level here] around? Fortunately, I gained more confidence and autonomy as the year went on, but I certainly experienced extreme Imposter Syndrome at the beginning. (Photo from here)

First Day of Intern Year                       

I'll never forget my very first day of intern year: I started off on the Stroke service (Internal Medicine residents at Duke complete a few weeks of Neurology every year during their training). Looking back, it's embarrassing to think about how little I knew at the time. I never got paged as a medical student, so when my pager went off for the first time, I didn't even realize that it was mine. 

As a medical student, no one will yell at you for accidentally leaving your pager at home, or for forgetting your stethoscope or other examination supplies one day. As a resident, you wouldn't dare leave anything behind. In the mornings before driving to the hospital, I got into the habit of double-checking to make sure that I had my hospital ID, pager, stethoscope, face shield (when it was still mandated we wear them), alcohol wipes (to clean my stethoscope), and most importantly, my phone, which is always a lifeline at work. 

Anyway, my JAR (junior assistant resident; second-year resident) had to tell me that it was my pager going off. When I silenced it, I didn't even know how to work it to read the entire message. I internally scolded myself for not fiddling with it ahead of time to figure out how to properly navigate its functioning. The page was about my patient who now had low blood pressure and was feeling symptomatic (lightheaded). His other vitals were fine. I stared at the page. It suddenly felt like all knowledge I may have had about hypotension washed out of my brain. I also didn't know this patient very well as it was my first day on the service. I was finally able to move my feet to find the nearest phone to call the nurse back and ask for more information. She sounded so calm. I was so nervous. 

"Hey Dr. Rose, Mr. E's blood pressure is 86/49 after checking it three times. He says he's feeling a little lightheaded but is otherwise stable. His other vitals look fine. Do you want to give him fluids?"

I froze. Wow, she just called me Dr. Rose. That's me. I pinched myself to re-focus. I had to make a decision. But I wasn't sure what to do! I turned around to see that our team was still rounding. The attending was teaching about common stroke etiologies and the medical students, nurse practitioner, and JAR were listening intently. Crap, I didn't want to pull my upper level away to ask for her help with something this simple. I wracked my brain for what to do next. The nurse, sensing my hesitancy through my silence, offered, "We can give him fluids. They gave some when this happened before. How much do you want to give?" 

I wanted to kick myself. I didn't even know what to tell her for how much or what kind of fluid to give.  "Um... how much fluid did he get before?" I finally got some words out. 

"One liter of normal saline," she replied.

"Okay, let's do that," I told her, happy to have resolved this so I could return to rounds with the rest of the group.

"Sounds good. Would you mind putting in an order for the fluid?"

I froze again. I didn't know how to put in that order! Darn, I didn't know how to do anything. I felt so incompetent. Fortunately, my upper level had by now broken away from the team to see if I needed help. She saved me by showing me how to put in the order. The patient remained stable and his blood pressure improved slightly with the fluid bolus, but later that afternoon we explored and aimed to address the reasons why his blood pressure was intermittently dropping.

Now, one year later, I know exactly how I'd approach this situation differently. After getting the page, I'd call the nurse back while reading through the patient's chart to get information more quickly. I would ask for the other vital signs. If they're unremarkable, I'd clarify where and how exactly the blood pressure was measured. Sometimes the read is inaccurate because the blood pressure cuff is not tightened properly or it's placed on the patient's forearm or leg (yes, this has happened before). I would then, in no particular order, and while reviewing information in the chart, inquire about where the patient's blood pressure usually runs (i.e. is the 86/49 reading just slightly lower than a baseline of 90s/50s?), if he was mentating well or experiencing any other symptoms, if there were any concerns about an infection, if he had a history of heart failure, advanced renal disease, or cirrhosis (to determine how much fluid to give him), etc. The nurse would probably be able to answer most if not all of these questions. I would then fill in the gaps with my chart review. It's important to gather and synthesize information quickly to determine the next steps.

If there was any indication that the patient was acutely unstable, such as other concerning vital signs (i.e. needing oxygen to breathe, very fast heart rate) or looking unwell (i.e. pale, perhaps frank bleeding from a clear source such as the rectum), I would not waste time reviewing his chart. I would immediately go to the bedside to evaluate and stabilize the patient. 

I hope to grow in these other important areas as I continue on in my training: 

• Pathophysiologies: My co-interns and I worked our butts off in medical school to solidify our understanding of numerous pathophysiologies that underlie disease processes. As an intern, though my many patient encounters helped hone my knowledge base, I still felt much of this mastery slip away because I wasn't using certain concepts. Lord knows much of the minuscule basic science details we needed to master for Step 1 have dissipated from many residents' minds. I remember more from my Step 2 studying, and perhaps even more from Step 3, but the knowledge I am not using or cases I'm not seeing often (i.e. biostatistics concepts, management of certain cardiologic emergencies such as pericardial tamponade, specific infectious diseases, etc) has inevitably faded. Fortunately, this knowledge is revived and sharpened with more experience and patient encounters.

• RRTs/Codes: (RRT = Rapid Response Team; a patient is unstable, Code = code blue; a patient's heart stops). Throughout the year, I was involved in multiple RRTs and a handful of codes in the inpatient setting, but I led few. I aspire to emulate my senior residents who are confident leaders in emergent situations such as these in the hospital. It takes tremendous skill to calmly, efficiently, and effectively lead a team of clinicians (nurses, respiratory therapists, pharmacists, etc) to achieve optimal quality of care for an unstable patient.

• Goals of Care discussions: Leading conversations with families and patients with terminal illnesses about life-sustaining interventions is such an important skill to hone as a provider. My uneasiness with goals of care discussions stems from a traumatizing experience on the general medicine service: I cared for a patient with terminal bladder cancer who we planned to discharge to home hospice per his wishes. However, the day prior to discharge, he developed major clotting in this bladder that we presumed eroded into a nearby artery, causing massive bleeding. This was completely unexpected. My attending swiftly and gently led a discussion with the daughter about the possibility that the patient could pass away that evening. 

Unfortunately, he died sooner than that evening. After our conversation with the daughter, the attending and I exited the room to place comfort care orders, but not too long after those orders were signed did we hear the daughter scream. A nurse came rushing over to the work station. She tapped me forcefully on the shoulder then waved me over. "We need a doctor, we need a doctor!" She then rushed back into the patient's room. The attending and I were on her heels.

When we entered the room, the daughter was still screaming. Her knees buckled, her head bowed and grazing her father's face, her hands tightly gripping the head of the bed. "Please know that I did all I could!" she cried. The patient looked very pale; he was staring into the distance with lifeless eyes. The nurse looked at me and the attending and shook her head gently before averting our gaze, as if to say, "He's gone."

Another nurse grabbed hold of the daughter before she lost her balance. She was then led out of the room. That was the first time that I pronounced a patient dead. I heard the daughter's screams in my sleep that night. I remember waking up in a panic to those screams, distressed and heartbroken.  

Moving forward, I know that I will lead more goals of care conversations with patients and their families. It is important to be able to do so with deep empathy, candor, and compassion.

Halfway through Intern Year

I cannot believe that we are halfway through intern year and approaching the end of 2020. 2020 overall has been an emotionally overwhelming and stressful year, needless to say: the COVID-19 pandemic, social isolation from our loved ones and peers during the quarantine months, the racial tensions and social injustices running rampant in our nation, the 2020 presidential election (though the outcome was a relief)... it has overall been an absolutely crazy year. Let's not forget the deaths of famous individuals such as Kobe Bryant, his daughter, and Chadwick Boseman. 

It has been stressful as well. I hit an overall low point in November when I worked 14-hours most days on one of the busiest services in the hospital: General Medicine. I was pushed over the edge, however, when a couple of other stressful events took place in my personal life, including with my family. I went into a depression during this time and made it a point to reach out to my therapist and someone through our Employee Assistance Program. I was grateful to also have the support of my PD, co-residents, and other administrative staff in the program.

General Medicine was the hardest rotation I worked on all year because of the long hour days and immense amount of information that quite frankly, I'm still trying to master. It was an exhausting couple of weeks. Intern year so far has taught me tremendous humility and resilience. 

After General Medicine I was scheduled to be on Geriatrics for a couple of weeks before a one-week Christmas vacation. The New Year will bring another 2.5 months of the General Medicine rotation, and a few weeks here and there of Ambulatory (clinic), Rheumatology consults, Pulmonology consults, Cardiac Intensive Care Unit, and Emergency Medicine. 

Hoping for a fresh, new start in 2021 :) Thanks for reading this short udpate!

Beginning of Intern Year

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

Picture from here

Another patient we admitted to our service was a 30-year-old man with cystic fibrosis (CF). He was hospitalized many times before due to poor compliance with therapy and substance use. 

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." 

He was a difficult patient in terms of compliance and lack of decorum at times. I found myself balking often when I first met him as he tried to make the case for medications (i.e. ativan) that we simply couldn't give to him. He's taught me to be stricter and firm in my and our medical team's carefully thought out decisions, regardless of his temper tantrums and disrespectful responses. It is important to stand firm and demonstrate resolve when dealing with patients like this. I will carry this on with me throughout the rest of my training and career.

Thank you for reading!

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