Diary from a Week in Practice
Am Fam Physician. 2003 Jun 15;67(12):2513-2514.
“Thank goodness that horrible crawling sensation in my legs has gone away completely,” reported the 66-year-old woman. She had been hospitalized a month earlier with microcytic anemia, which ultimately was diagnosed as chronic gastritis secondary to nonsteroidal anti-inflammatory drugs. Although her presenting hemoglobin was 7.2 mg, she had denied fatigue, weakness, or even any abdominal discomfort. Her chief complaint was a severe, burning, creeping pain in her legs at night. She felt compelled to get out of bed and pace the floor night after night, and she was completely exhausted from lack of sleep. Third-year resident, AN, diagnosed her with restless legs syndrome. The work-up included a complete blood cell count and iron studies, the latter of which prompted him to admit her to the hospital for evaluation of iron deficiency anemia. The patient felt a lot better after receiving two units of packed red blood cells, and she was dismissed with oral iron tablets. Today, her hemoglobin level was 11.2 mg, and her restless legs syndrome was cured.
He was 36 years old, homeless, an active drug user, positive for human immunodeficiency virus (HIV), and now was admitted with Pneumocystis carinii pneumonia. AR, the first-year resident on the case, was unsure what he could do to help this young man. His patient had known he was HIV positive for at least five years. He had seen several doctors and been given many prescriptions for antiretroviral medications, but he never took the medications with any consistency. Several admissions into drug treatment programs had been unsuccessful. This young man simply could not stay away from cocaine. AR spoke with the patient every day he was in the hospital, encouraging him to try another treatment program. “I know I'll never make it,” the patient said. “Frankly, I don't want to think about living without drugs.” AR remembered a palliative care lecture that focused on individualizing treatment goals. For this particular patient, getting off drugs was not a feasible goal. But, now that the patient was experiencing his first serious HIV-related infection, AR thought he had a good chance of convincing him to take his medications regularly. He went to see the patient with a renewed determination to help him in a different way.
“When she was two years old, she had such a bad reaction to her second hepatitis B immunization that the doctor held off on the third dose,” reported second-year resident, KG. He had just seen a 10-year-old girl who presented for routine immunizations. In addition to hepatitis B, Texas law now requires two doses of hepatitis A, six months apart, for every school-aged child in our county. As KG reviewed the fourth grader's shot record, he noted that her previous doctor had written a note explaining that the girl ran a high fever the evening of the second hepatitis B shot. Understandably, the girl's parents were anxious about having their daughter immunized. TA, the attending in clinic, suggested that KG review the adverse effects of hepatitis B immunizations on the Centers for Disease Control and Prevention Web site (www.cdc.gov). He quickly accessed the site and found documentation that placebo-controlled studies have demonstrated fever is no more common after hepatitis B injections than after placebo. KG showed the findings to the child's parents and discussed the pros and cons of vaccination. Shortly thereafter, the child received both hepatitis A and B immunizations. “I'll see you in six months,” he told her. “Please, no more shots!” she begged as she ran for the exit.
When she heard that a patient of hers had died suddenly overnight, KS sat down for a moment and said a silent prayer. The 62-year-old man had been admitted over the weekend to the Family Practice Service because he did not have a regular doctor. He had many chronic medical problems that he virtually ignored until becoming acutely ill with pneumonia. KS saw him only twice before another faculty took charge of the rotation. What struck her most during those visits was that he seemed lonely and afraid. In retrospect, KS was glad that she had spent a few extra minutes with him—not only to explain his medical problems, but also to lend a sympathetic ear. When she asked about his family, he said they lived in a different state, and he did not want them called. As far as she knew, he had no visitors. The patient had been recovering from the infection when suddenly he was found by one of the nurses to be in asystole. A Code Blue was called, but cardiac resuscitation was unsuccessful. KS was sad that the man had died alone. In the practice of medicine, we never know what the day will bring to each of our patients. Those few extra minutes spent at our patients' bedside may be more meaningful than all of their medical treatment.
“I know that I can't play baseball, but how about basketball?” asked the 15-year-old girl, her voice full of despair. Both mother and doctor responded, “Of course not!” simultaneously. The teenager had injured the fifth finger of her right hand catching a baseball during a big district playoff game the night before. The finger was swollen, purplish, and painful. An x-ray confirmed a small nondisplaced fracture of the proximal aspect of the middle phalanx. “We have three more playoff games this week,” the patient moaned. “What will Coach say?” KS tried to console her patient as she applied a finger splint, reassuring her that the fracture would heal completely in a few weeks. As she discussed the use of ice packs and pain relievers with mother and daughter, KS could tell that the teenager was not hearing a word she said. Her last question, as she left the examination room was, “Can I at least run track this afternoon?”
As her pager silently vibrated during the opening strands of a Rachmaninoff rhapsody, KS gave thanks that she had remembered to turn the sound off just minutes before the music began. It had been an unusually quiet day on call, and she had been hoping for a quiet evening as well. “Just my luck,” she thought to herself, and she looked around to find the exit. Thankfully, her husband had procured aisle seats, so she could quietly leave the orchestra hall to answer the page to the emergency room. JH, the second-year resident on call for the Family Practice Service, was admitting one of the nursing home patients for pneumonia. KS frequently attended in the nursing home, and she was familiar with the patient and his host of medical problems. She felt comfortable reviewing the treatment plan with the resident and planned to see the elderly man the next morning on rounds. She apologized to the resident for taking a few minutes to answer the page. “No problem,” said JH. “Enjoy the rest of the show!”
In order to preserve patient confidentiality, the patients' names and identifying characteristics have been changed in each scenario.
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