Residency Diary: My Second Year: October and November 2016
KeywordsChronic Pancreatitis Bursitis Chiari Malformation Transitional Care Junior Resident
Wednesday, October 2016
I knew before I stepped foot in the clinic room there was no way we could help Nancy (names changed here and throughout). She fractured her proximal humerus while walking her dogs and suffered a number of postoperative complications following surgery—an infection requiring removal of hardware and placement of an antibiotic spacer and an additional surgery to have the spacer removed and the subsequent nonunion fixed. Now, nine months later, she was still having pain in her shoulder.
I examined Nancy’s x-rays with my attending before entering her room. The fracture seemed finally to have healed, increasing the chance we might do harm in exchange for little benefit.
I entered Nancy’s room and introduced myself. Although her shoulder certainly improved, it still hurt when she tried using it throughout the day. I noted her extensive surgical history while she told me her story. When she got to the end, I said the first thing that popped into my head: “It sounds like you’ve been through a lot.”
It was as if I had given her permission, or maybe she just felt comfortable enough with me at that point, to take off her mask, her front for the world that said “everything is alright.” She told me about her struggles with a Chiari malformation and how surgery for it gave her seizures, balance problems, and cognitive issues that were so severe she had to quit her job. She talked about a cancer diagnosis several years ago, and how lucky she felt to be in remission. She explained how she feared her health was deteriorating and how she was afraid she wouldn’t be around to take care of her husband.
In the end, we prescribed physical therapy for Nancy. She was a high-risk surgical patient with a high number of medical comorbidities. We explained that the risks of surgery were too high to justify any potential benefit, and Nancy agreed. We talked some more about her pain and the prognosis and then she left.
A few weeks later, a thank you card from Nancy arrived on my desk. In her note, she thanked me for listening to her.
Visiting with Nancy reminded me that every encounter—with or without surgery—begins with a story. I just need to take the time to listen.
Thursday, November 2016
Keith was my first patient who tried to die on me. He had lived his life hard, drinking and battling inner demons that made relationships difficult, all of which took its toll; he looked at least twenty years older than his stated age. At one point, things were looking up. He got sober and quit the opioids for his chronic pancreatitis—at which point he came down with septic prepetellar bursitis, which was unusually difficult to eradicate. As he went through multiple irrigation and débridements, he told us it was God’s way of punishing him for a lifetime of poor choices.
When Keith first presented, we débrided his prepetellar bursa of thick, yellow pus. He got a deep vein thrombosis, and his leg swelled even more. His pain never improved, and his white blood cell count climbed. His wound started to drain, and the infection tracked up his leg. His skin over the knee grew necrotic and died. We took him back for another washout and a wound vac.
That evening, I was on call when Keith’s nurse paged me that his wound vac was malfunctioning and blood was saturating through the dressing onto his bed. I swapped out his wound vac, and made sure nothing was wrong with the machine. Later, the nurse paged me again—Keith saturated another dressing. The machine was not the problem, Keith was bleeding. I discussed the problem with my higher-ups, updating them as the night went on, and tried not panic. I had no experience dealing with this type of situation, so I took a step back and thought what I might say to a junior resident if I was a senior—who knew what she was doing. I drew a hemoglobin. I changed the wound vac dressing, and made sure there were no leaks. Keith was miserable, but his vitals were stable.
A few hours later, he saturated another dressing. This time, his hemoglobin drifted downward. I reinforced his dressing and decided to reverse his anticoagulation. I ordered another hemoglobin for a few hours later. But before we got that, he again saturated his dressing, and I again changed the dressing, replacing it this time with a pressure dressing. Keith, now pale and feeling dizzy, howled in pain. He became tachycardic and his blood pressure spiraled down. He was entering hemorrhagic shock. I gave him a blood transfusion and booked him for surgery for the morning before transferring him to the ICU for the remainder of the night.
Following surgery, Keith finally stabilized. He was in pain and his spirits were low, but he looked at me through his misery and apologized.
“I’m sorry I did that to you last night,” Keith said. “You were in here all night changing the dressings over and over again.”
“Sorry? My goodness, no! I’m sorry you had to go through that. I hate to see you suffer like that.”
“I must have really scared you, huh?”
I grew a little defensive. “I wasn’t scared. I was just worried—concerned about you.” Keith smiled.
Keith stayed for numerous more irrigations and débridements. He stayed for wound coverage, for poor pain control, and because of difficulty with placement in a transitional care facility. While there was some incredulity on rounds that Keith was still in the hospital, I didn’t mind. Keith and I had a mutual understanding. We had shared the harrowing experience of the night he tried to die, but didn’t.
Saturday, November 2016
Derek’s car spun out on the highway during a typical Minnesota snowstorm. Derek had gotten out of his car to inspect the damage to his car, when an oncoming vehicle had crushed him into the central median. The injury to his foot was so severe that the trauma doctors who first received Derek broke protocol, adding him to the OR schedule for the on-call orthopaedic surgeon before I even had a chance to examine him. While I was on my way downstairs to the emergency room, I received a call from the OR control desk wanting to know what was going on.
“I don’t even know what procedure we are doing!” I explained, annoyed by the trauma surgeon’s breach in protocol, even if he was an attending. “I haven’t even seen him! They took him from the trauma bay right to the CT scanner.”
Finally the college-aged patient was back in the emergency department. I took down the dressings and discovered what had startled the trauma doctors. Derek’s foot was insensate and pulseless. His skin was avulsed from his ankle to his mid-foot. His foot was mostly disarticulated from his ankle and his foot was attached to his body by three tendons.
Derek had been outside in the Minnesota winter for some time and was shivering. He was screaming in pain. He knew that his foot was injured, but he had not seen the extent of his injury. This was the worst injury I had ever seen to a limb.
I approached Derek, who had three large Greek letters tattooed down his side. He was solidly built and would not look out place in a fraternity house, though he certainly looked out of place on a hospital gurney. I knew the reality of his injury—the surgeries, the rehab, and the struggle that lay ahead. Derek knew none of it, only a blinding pain in his foot when it moved. How could I transfer all that reality from my mind to this young man, his adult life just beginning? It seemed cruel to do it; but equally cruel not to.
“Derek,” I started. “You have a very severe injury to your foot.” His face fell. “You’re going to need surgery.”
“Surgery?” Derek questioned in alarm. If Derek did not realize that his injury was severe enough to require surgery, I didn’t know how I could tell him the rest. This task seemed impossible, inhumane. I paused, trying to find the right words to make the next sentence hurt less. But there was no way to make the words land peacefully. I pressed on.
“Yes, surgery. This injury is very severe. I need you to understand that. We will do everything we can in surgery, but I think it is important for you to know that there is a good chance you will lose your foot.”
And then Derek began to weep. His friends, who had arrived after the accident, held him as he sobbed. This big, sturdy, young man cried openly as the future I saw for him replaced the one he long envisioned for himself. I stepped back and let his friends take over. I didn’t know what to say to make it better, so I said nothing at all.