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November 6, 2004 Internship Journal

The last time I asked the HIV patient's occupational therapist how he was doing, she told me that he had screamed at her to get out of his room and he had grabbed his mother by her hair. Slowly but surely I am starting to accept the fact that I can not win them all.

I started neurology on Monday, November 1. This is the most relevant month to my career, so I have been looking forward to it. In addition to this, my attending, Dr. Lee, is wonderful. He is the attending that everyone hopes to get. On Monday, the service only had nine patients on it and there are two other interns plus a fourth-year medical student on the team with me, so I was only assigned two patients on Monday. One of them was a lady with multiple sclerosis who was going home on Tuesday, and the other was an 84 year old named Mr. Daniels who was supposed to be transferred back to the hospital where he came from on Monday.

Mr. Daniels was admitted to the ICU on October 22nd as a transfer from an outside hospital. He had been admitted three days previously for unresponsiveness. He had had seizures in the past, so this was ruled out. He had not had a stroke, and he had not overdosed on any medicines. He was then diagnosed with a metabolic versus hypoxic encephalopathy. In English, a hypoxic encephalopathy is a result of a lack of oxygen to the brain and a metabolic encephalopathy is just a blanket term for any metabolic disturbance causing the brain not to function well. In his case, his kidney failure is probably the cause of this.

Mr. Daniels was officially mine at noon on Monday. At 1230, I received a page that his son wanted to speak to his dad's doctor. Great! I went and reviewed the chart before I called him. As I flipped through the chart, I saw how the doctors taking care of him in the ICU had ruled out each reversible cause of his metabolic encephalopathy. Unfortunately for him, as this was going on, he was not getting any better. He had a feeding tube placed and a tracheostomy because he was not making any progress towards getting off of the ventilator. The last few notes that I read all said "poor prognosis."

With this information, I called Mr. Daniels's son. I was told that he was unhappy about the transfer that was supposed to occur that day. He asked me if they could not treat him at the outside hospital before, how they were going to be able to treat him now. I had to explain to him that unfortunately there were no more treatments for his dad. I explained to him that Mr. Daniels came to our hospital for an evaluation by a neurologist and that all reversible causes of his dad's altered mental status had been ruled out. He replied by saying, "so he has just in the healing phase now." I said "Sir, I know you cannot see me, but I'm a quadriplegic. I promised myself a while ago that I would never give anyone false hope, so no, he is not in the healing phase. Unfortunately, he is most likely not going to get better. I then apologized to him for having to be the one to tell him this, and acknowledged that this is a lot to deal with. He thanked me, and we ended the conversation. It was the first time that I had to give anyone bad news, and I thought I did a good job.

I was on call Wednesday night. When I'm on call, I cover all of the neurology patients and all of the hematology/oncology patients, and I admit patients to both services. Luckily, I only had one admission Wednesday. Mr. Edwards is a 66 year old guy who has been deaf, mute and blind since he was 16. He had been admitted to an outside hospital after having a seizure on Friday night. He was then found to have a pituitary adenoma, so he was transferred here for further evaluation. The pituitary gland secretes hormones. About 10% of us have pituitary adenomas. These are benign tumors of the pituitary gland that cause problems when they a) secrete hormones or b) get so big that they compress the nerves going to the eye. His was doing neither.

Obviously, I could not take the history from him. His two sisters and brother were there. One of the sisters had lived with him and helped him for the last 19 years. He was fairly independent though, showering himself, feeding himself, etc. But for the last three months, he had been steadily declining. Now, he was unable to walk on his own. I spoke with the family about their expectations and told them that Dr. Lee and I would see them in the morning.

On rounds the next morning, I was greeted by one of the sisters with a hug. They said they were very impressed with me. We explained to them that the tumor did not cause his seizure, and that it was probably from one of his old strokes. Our plan would be to get an EEG (electroencephalogram), which is used to detect seizure activity, and to get a neurosurgery consult. I was post-call, so I went home after rounds without thinking any more about him.

When we rounded on him yesterday, the family was not around. After several missed attempts, I finally caught up with them in the afternoon. They were quite unhappy that he had not been out of bed, and that we were thinking about sending him home. They were requesting that after we were done evaluating him, he be transferred to a skilled nursing facility near their home. This is basically a section of a nursing home where patients can get therapy. They do not like the thought of him going to a nursing home, but they also realize how much care he would need right now, and they want the best for him. This discussion brought the sister who hugged me to tears. I told them that I was sorry that he had not been out of bed, and that I would get the physical and occupational therapists to see him to make a recommendation on what they thought would be best for him. Then Mary helped one of the nurses get him out of bed and into a chair. I felt badly that I did not order for the therapists that day, but there was nothing that I could do about it now. Hopefully, I can learn to think about this earlier.

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