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Unforgettable


 

Recently The Hospitalist asked readers to share their reminiscences of patients who had left their mark in some special way on the docs’ lives. Here are those stories.

Patient al Dente

Sandi Verbin, MD, pediatric hospitalist at Temple University Children's Hospital, Philadelphia, and part-time pediatric hospitalist at Holy Redeemer Hospital, Meadowbrook, Pa.

It was midnight in the ER. My shift was ending, and I had to be up early in the morning to drive to my niece’s third birthday party about two hours away. The ER showed no signs of slowing, however, and one of the nurses approached me, asking if I could see the “quick” patient in Room 4: a child with a piece of macaroni stuck up his nose.

In over 10 years of pediatric practice, the allure of placing foreign objects in body orifices has eluded me. Why is this fun? Nevertheless, a parade of toddlers have presented themselves to me with such varied objects as crayons, tissue paper, beads, coffee beans, Play-Doh, M&Ms, rocks, and magnets in their ears and nostrils. (This doesn’t count the unfortunate innocent bystanders who presented with insects having claimed “squatter’s rights” to the patients’ auditory canals.)

Invariably, when asked, the children deny knowing how the object came to be there—at best, a lame “it just fell in” is offered. When questioned as to how the offending object came so close to the involved area, I am met with silence or a shrug. One memorable child told me he did not believe I was the doctor because I was a girl. I let it pass, considering he had put a rabbit food pellet in his ear after being dared to do so by his older brother. I felt his overall judgment was somewhat questionable.

I entered Room 4, prepared to see the usual anxious—or, as in some cases, oblivious—toddler. Instead, to my surprise, a sheepish-looking eight-year-old boy sat on the table, accompanied by his exasperated mother. The pair had been waiting for several hours for the anticipated pasta-ectomy.

Unable to stop myself, I blurted out, “What is a big boy like you doing putting macaroni up his nose? I expect to see this in little kids, but not eight-year-old boys!” The child answered that he had put the macaroni up his nose “when I was in preschool.”

“You mean five or six years ago?” I asked incredulously. When he reluctantly said yes, I explained that I would look up his nose, but that that piece of macaroni was long gone—dissolved or swallowed lo these many years ago. Sure enough, an exam revealed turbinates and mucus but no complex carbohydrates.

I explained to the mother again that there was no way the food item could have survived in the child’s nose for five years, that he would have presented with sinusitis years ago had the macaroni not been swallowed, dissolved, or sneezed out, and that there was no place else to which it could have migrated.

My best diagnosis was that the child had an unusually dry, sharp-feeling piece of mucus in his nose. The discomfort of this had caused him to admit his transgression, committed in the reckless days of toddlerhood, one which had clearly been a source of guilt for him ever since. After some saline nose drops, and no doubt due in no small part to the soul-cleansing effects of confession, the boy felt better. He and mom went home.

I left the ER to contemplate what antics the next day’s group of three-year-olds would cook up. I vowed to keep a close eye on the Jelly Beans.

I thought, “What are this baby’s chances?”

Great Foster Mom

Alison Holmes, MD, MPH, pediatric hospitalist, Concord Hospital, Concord, N.H., and assistant professor of Community and Family Medicine, Dartmouth Medical School, contributed two stories.

When I was a resident, there was one chronically ill baby who was born at 34 weeks and had significant cyanotic heart disease. He would need a number of high-risk cardiac surgeries, and he also had a portion of his small intestine removed for necrotizing enterocolitis [caused by] his prematurity. After that it can be hard to absorb [nutrients] and grow. The baby had a lot of trouble with diarrhea and dehydration. We put him on the GI service, and the fluid overload from rehydration caused him to go into heart failure, and nobody could ever get the balance right.

He’d go back and forth between the GI service and the cardiology service. All the residents knew him, and he was in a horrible social situation. His mother was a drug user, and after his birth she never visited; we didn’t know anything about the father. The baby was this high-risk infant who basically had laid in the hospital with the TV on for the first five months of his life. Nobody paid attention to him, and I remember thinking, “This is horrible. He’s not going to get any love or nurturing. He’s not going to be normal, because nobody picks him up and holds him and talks to him.”

He was discharged into foster care, and I became his primary doctor. He just had the greatest foster mother in the world. She didn’t care that he had these medical problems; she was so glad to have a baby. She had been a foster parent for a while and had cared for troubled older children and had had enough of that, and she had her own 11-year-old. She was so thrilled to have this baby, and she just loved him and loved him and loved him.

I watched over the next year as he regained normal development despite all his early setbacks—both medical and social. Eventually his father did get involved; he went back into the father’s care, and the father rallied his whole family. The foster mother stays in touch with the family and is the child’s godmother.

By the time I finished residency, he was about three and a half years old, had been through three major cardiac surgeries, and was completely developmentally normal. I’ll never forget that no matter what we do medically, it’s people like that foster mother who make a difference for children.

Doing Wonders

I cared for a growth-retarded baby whose mother was in her late 30s. She was a drug user, and she had lost custody of her three prior children. Here she was with a fourth child, without any supports. She had used cocaine until about the fifth month of her pregnancy, when she decided to get some help.

I thought, “What are this baby’s chances?” But [the mom] did it. She did not go back to using drugs. She stayed clean and reconciled with the father. Life wasn’t always so kind to her. She couldn’t always hold down the same job, but at least she always had a job. She did wonders for this little girl, and she was able to turn her own life around.

Which patient or doc do you admire?

Throughout 2007, The Hospitalist will be publishing additional stories about patients and fellow healthcare professionals whom our readers admire.

If you have someone in mind, e-mail your contact information to ldionne@wiley.com, and we’ll arrange for our writer to contact you.

Yet One More Challenge

Sandeep Sachdeva, MD, hospitalist at Swedish Medical Center; lead hospitalist, Swedish Medical Center’s Stroke Program; and clinical instructor, University of Washington, Seattle.

The patient I was most impressed by was a lady who came into the hospital about a year ago. I think she was in her mid 60s and had been blind and deaf from birth. She had obviously faced huge challenges and was living alone.

She had a very good support system: a non-governmental organization (NGO) here that provides close support for people in this type of situation. Even though she didn’t have any family support, these volunteers from the NGO would come out to make sure she was doing OK.

As I recall, she had tripped over something and had fallen and broken her hip, and she was admitted to the hospital for hip surgery. Just looking after her was a tremendous learning experience for me: She couldn't see me; she couldn’t hear me; and the only way we could communicate was through a sign language interpreter, where she had to feel the hands of the person doing sign language. She was very involved in her own care; she would ask questions, and there was no dearth of communication.

It was fascinating to deal with this lady who is—in essence—in a different universe with no sound and no sight, and who was facing the challenge of being in the hospital and recovering from her surgery. It felt very satisfying to look after her and to be inspired by her—a patient who was able to overcome yet another challenge when she is already disadvantaged. She did very well, and I believe she went home. I could still feel that she was trying to be independent and be the take-charge person that she had always been.

Patient in a Pickle

Eric Kupersmith, MD, assistant professor of medicine and director of the Hospitalist Program at Cooper Hospital, Camden, N.J. Dr. Kupersmith has plenty of patients he’ll never forget. Here are the stories of few.

There was a patient who would get admitted every month with congestive heart failure. He would develop pulmonary edema as an acute event like clockwork, and no one could figure out what was causing this. The seventh consecutive time, he was placed on my service. We eventually discovered that each month he would buy a jar of pickles and eat the whole jar. Then—at the end of the month when he finished the pickles—he would drink the entire jar full of juice.

The salt in the pickle juice caused the acute pulmonary edema, but until this piece of history was taken no one could pin down the problem. It really was a medical mystery. Figuring it out prevented his readmissions and is just the kind of thing that represents how hospitalists sometimes have to serve as diagnostic detectives.

You and Who Else?

An old woman was brought in by someone and was admitted to my service. When I entered the room, the daughter who lives [with] and cares for her said, “I know she has cancer, I know she’s demented, I think it is time to let her go. I live with her. I’m her power of attorney. There’s no document, but I’m her only daughter.”

What do I do? I figure hospice care; she’s dying in the hospital. I don’t cure her pneumonia. I let her go, and—three days later [after she had died]—I get a phone call from her two sons.

They say, “Hi Doctor, we brought our mother in. What’s the plan of care?” It turns out there was no power of attorney. The daughter did live with the patient, but apparently the daughter was mad at her two brothers, so she didn’t tell me the whole story. The sons threatened me—not with malpractice—but with going to tell the district attorney that I committed murder. And one of the sons mentioned murdering me.

Both threats resolved with tears and empathy as I met with them and acknowledged the error; after full explanations, they agreed with the final decision.

Put Bar Codes on Families, Too!

A mildly demented older man was admitted for something small. In comes another man and says, “This is my brother, and he’s ready to go.”

“Really?” I asked. “That’s your brother?”

“Yes,” he answered. “That’s my brother Jim.”

“OK, great,” I replied. And Jim takes him home.

Two hours later, the family shows up and tells me he doesn’t have a brother. It turns out that at the church the patient attends, they call each other “brother.’”

When They Know, They Know

I got called to see a patient. “What is the matter?” I asked him.

“I’m dying,” he said.

“What do you mean?” I asked. “Do you have chest pain?”

“No,” he replied.

“Are you short of breath?” I asked.

“No,” he said.

“Are you feeling a fever?” I asked.

“No! I’m dying!” he exclaimed.

I found nothing from the interview. I did a physical exam and found nothing. I called other physicians in who were seeing the patient. Everyone said, “I don’t know what he means.” The patient died within the hour.

I’ve had this happen to me four times. In three of those cases, they said, “I’m going to die today.”

In the other case, the patient said, “I don’t feel right.” When I asked him what he meant, he said, “I don’t know. I just feel weird.” And then he died that day.

Ask the Patient Why

I have a number of patients with sickle cell disease who have chronic pain syndrome. I had a female patient—about 26 years old—who basically stayed immobile for two weeks. The staff was upset with her about that.

To each other, they referred to her as noncompliant, and we wondered, “Why won’t she get up? She won’t even try to get out of bed.”

When I was assigned her case, I said to her, “Everyone says you won’t get out of bed. Will you tell me why?”

“You’re the first person to ask me that,” she said.

“Well, then,” I asked, “why?”

“I have an artificial hip,” she said, “and it is dislocated.”

When the physicians and other staff had urged her to get up, she had simply said, “My hip hurts.” It turns out that she was clinically depressed and was angry because she felt frustrated that she was always being judged.

Ultimately, she died two years later from the same problem in another hospital where she had developed DVT. In that other hospital, she’d done the same thing: She had refused to move, and the staff had told her she had to move—but no one had asked her why she hadn’t. TH

Andrea Sattinger writes frequently for The Hospitalist.

The Doctor I Most Admire

Dr. Kupersmith, on the physician he most admires:

Edward D. Viner, MD, has been chief of the Department of Medicine at Cooper University Hospital since 1987 and is professor and vice chairman of the Department of Medicine of the University of Medicine and Dentistry of New Jersey/Robert Wood Johnson Medical School, New Brunswick. He also serves as interim director of the Cancer Institute of New Jersey at Cooper University Hospital, Camden.

Dr. Viner has been one of the most influential forces on my career and life, ranking up there with my parents and popular heroes. His personal characteristics are remarkable and cannot be overstated. His sacrifice, dedication, wisdom, intelligence, vision, and passion make him second to none in his ability to build a massive department, cultivate a student’s skill, hone a young practitioner into an excellent physician, and provide care for an ailing patient.

Dr. Viner combines an old-fashioned approach of detailed personal relationships with technology, quality, and system efficiency. The sacrifice is his personal time, but he may argue that it’s no sacrifice because he loves what he does, which is caring for everyone: patients, students, residents, faculty, and the health of the organization.

One of the most inspirational things about him is that he gives patients everything he has, sacrificing—innumerable times—his personal time and private life for the sake of his patients and colleagues. Whether conducting home visits, coming to the hospital, or going with a frightened patient to a surgical appointment for a breast biopsy to guide her through it, his dedication to others has always come before things in his own life.

He has grown our department from fewer than 10 to 165 people, putting it on the map with a four-year medical school. He takes care of and inspires his staff as he cares for his patients. He is open to facing his mistakes as well as embracing his successes. He leads by example. What he asks of others, he delivers himself—and more. He is intimately involved in scheduled events such as chief’s rounds and grand rounds. He has always been available to discuss his patients or any other clinical conundrum.

He is also a master diagnostician. His bedside teaching and problem solving provided me with an approach that has stuck with me and helped shape my success. It is also here that he demonstrated the importance of academic excellence; integrating this knowledge with empathy and persistence has proven to be the recipe for successfully caring for a patient and achieving academic success.

For instance, there was the case of a patient who was admitted to the ICU. I was one of the physicians assigned to this complex case. The patient presented with a stroke and Staphylococcus aureus bacteremia. On physical exam, I found this small cyst, a lypoma about 2 x 2 centimeters, near the site of a prior vascular surgery. The patient claimed that he’d had this cyst for at least 10 years if not his whole life. I noticed the cyst and mentioned it to my colleagues. Then the patient was crashing, and we couldn’t understand where the bacteria had come from and why this was happening.

Dr. Viner asked, “Why are we ignoring this lypoma?”

The team said, “Because it’s been there for so long.”

And he said, “Well, maybe you’re missing it; maybe you’re missing the boat.”

He aspirated the cyst, found pus, and grew Staph. It turned out there was a fistula from the surgery 10 years earlier. It had walled off an abscess that had been intermittently leaking for a decade. We had all discounted it, but because Dr. Viner had observed so much in his clinical career, as a hematologist/oncologist as well as a general practitioner in internal medicine, he picked it up.

His clinical acumen, knowledge of the literature, wealth of experience, and enjoyment of teaching (and learning!) made every interaction educational. He systematically controlled the flow of information in a way that integrated the history, physical and laboratory findings, pathophysiology, and treatment options into an amazing learning event. Dr. Viner consults experts all over the world on patient cases. He testified before Congress in the 1970s, advocating for the then-novel concepts of hospice and palliative care. He is still very active in these areas, helping patients to be comfortable and achieve their wishes at end of life and helping their families to be well informed and comforted.

The anecdotes are endless. He’s been taking care of the Philadelphia Orchestra for 20 years and is a prominent citizen, but he always has his doors open to the indigent of Camden, which is one of the poorest cities in America. He treats them all with equal respect and absolute dedication. You can still call him at home at 2 a.m. to run anything by him. He is a man who has chosen medicine as his life.

I’ve been in my field for 15 years, and I can imagine few others as brilliant and who have given everything they had to their patients and to staff. Dr. Viner is now finishing his last year as chief of medicine. He challenges me regularly to fulfill the highest ideals of physician leadership. Dr. Viner taught me that my life’s work can be my life's passion and [that] sacrifice pays off for everyone when you love what you do.—AS

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