Articles

Reflection on Medicine, Rotation 1.

In Medical Musings on June 22, 2012 by David

It’s amazing how many things happen in the hospital and how much responsibility that I have, even as a medical student. I told a patient with metastatic renal cell carcinoma that he was going to die. I closed at the end of brain surgery for a patient I admitted and talked to everyday for more than week. I interpreted for a mandarin speaking patient who came in with nonspecific chest pain, and left with a CABG, and developed a stroke and became aphasic. It’s a sign of how sick our healthcare system when you know your patient has less than a year to live, but it’s her insurance status rather than her prognosis that guides what tests we order and what procedures we do. It’s hard to talk to Utilization Review, even at one of the strongest safety net hospital of one of the most affluent counties in the United States.

But what’s most shocking to me, and what I have the hardest time struggling with, is how quickly lives can change. It’s amazing how one day, you can come into the hospital with no complaints, minor fatigue and just feeling under the weather, and leave a few days later after brain surgery and a prognosis on the order of weeks to months. Or you can come in with nonspecific chest pain, a normal EKG, one borderline troponin, and what can be described just as well as the prodrome of viral gastritis, and be sent for a CABG. It’s especially hard to think that you are doing the best for your patient, offering invasive but life saving procedures to patients who have no insurance, when you call to follow up and find out your patient who you advocated for to get a CABG developed a stroke postop, become aphasic, and stayed in the ICU for a week.

Mr. Y was a monolingual mandarin speaking gentleman who went to the ED with some non-specific chest pain after two days of the stomach flu. He wasn’t the most cultured gentleman, but he reminded me of my dad. He was a rather loud gentleman, with no sense of an indoor voice. Like my dad, he was a smoker. I still remember discussing with the team, whether he needed to be admitted – with some nausea and vomiting (perhaps because of the viral gastritis?), some exercise intolerance, and some nocturnal orthopnea, but with negative troponins, a normal EKG, and more concerned about his nausea and vomiting than about his chest pain. His chest pain seems to be chronic – perhaps an outpatient stable angina work-up would be enough?

As the only mandarin speaking member of our cardiology team, I spent a lot of time talking with him. We had long conversations on why smoking cessation is important and what it means to eat well. To me he complained about the hospital food, and I laughed in his face when he told me that he got the nurse to get him a hamburger and fries from the hospital cafeteria. I sat with him during his catheterization, and I translated for the cardiology fellow as he told Mr. Y that he had bad triple vessel disease, that there was nothing interventional cardiology can do for him as his coronary arteries are too bad and the plaque too diffuse for stents, and would probably need a CABG. I laughed at him again when right after he heard the news, and then told us that he was hungry because he was NPO for the entire morning and asked if someone could get him McDonalds now that we are done.

As a physician, there is so much responsibility. The idea of informed consent is hard, who can truly understand the implications, ramifications, advantages, disadvantages, challenges, and harms of an invasive procedure. It was especially hard for a patient like Mr. Y. Monolingual and poorly educated; Mr. Y was a migrant worker working as a masseuse in a mall in South Bay as the rest of his family was in China. When I asked for an emergency contact, repeated as the likelihood of CABG became greater, he could not name anyone. He was alone, in a country that does not even speak his language. Although I sat down with him and described to him in detail the surgery, he was almost indifferent, almost resigned in his trust of the medical team. Asking him to explain concepts back to us, all he would say is “I don’t really understand, but whatever you say I need, I’ll do.”

He asked me if a CABG was dangerous, and I looked him in the eye. “This is a very invasive surgery, they will need to open your chest and perform major surgery. There is the risk of complications, but we believe that this surgery can help you and we recommend you get the surgery.” I thought we were doing a good job. SGFH doesn’t even have a cardiothoracic surgeon – we called Moffitt/UCSF, got carotid ultrasounds, and PFTs, and kept him inpatient until the following week. I thought it was a triumph, an expensive surgery for a poor patient – an egalitarian use of resources and a good advocacy on our part.

One of the assignments for the medicine clerkship was to call a patient after discharge to help us think about discharges and to assess patients understanding and management after they went back home. During my last week, I finally got around to this assignment. I called his phone three times during the last week. Only on the third call did someone finally pick up, but it wasn’t Mr. Y. It was a nurse at Moffitt/UCSF. Mr. Y was still in the hospital so many days after the surgery? The nurse was actually an ICU nurse. Mr. Y suffered a stroke after the CABG, and this was his 5th day in the ICU. He was now no longer able to speak, aphasic and needing to be transferred to back to SFGH – potentially for a long stay before long term placement.

It’s always said that life is fragile, and that we should cherish each and every moment, but is so hard to know and truly internalize this bitter and cold truth. It is hard to be an advocate for people who depend on you when in there is so much uncertainty, so much risk, and so much danger behind every choice. As physicians, our job is to provide predictability, stability, and comfort. To explain, reassure, manage, care for, and love our patients. Even that alone is hard.

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