Florida State University College of Medicine

Pathographies

Medical student essays on patients from their third year rotations

All patient names are fictitious

The Recliner

by Cheyenne Andrew

Ifyouweretoaskmeto lay in a recliner for four hourscoveredin a mountain of blankets and read my favorite book, I would probably say yes. Ofcourse!Whodoesnotwant4hoursto relax in a recliner? But there’s a catch isn’t there? This recliner comes with kidneyfailure,itrequiresvascularsurgery to create an arteriovenous access, it comes with a machine that filters your blood500ml/minforthreetofourhours. A recliner that makes you feel tired instead of rested and cold instead of warm. It is an extra trip you will have to make3timesaweek;youmayevenneed to cancel your lunch date and take time offwork.

I replayed our visit when I met you at thehospital.Walkinginyourroomatthe crack of dawn with my papers and some notes I scribbled down from your chart. I was in a rush to report to my attending nearlytrippingovermyselfineveryroom. However, I saved your place for last. A fewminutesgoby,asIstandoutsideyour door; I re read my bulleted notes. 58-year-old female with a history of chronic kidney disease, type 2 diabetes, and hypertension; hospital day three. Consult to nephrology should have been made earlier, if not for a possible congestive heart failure exacerbation. Yourcreatinehadjumpedfrom2to5and your electrolytes were less than ideal. Yourkidneyfunctionbarelyhangingonat 17.Iforcedmybestsmileandopenedthe door. “Hello Mrs. K! I am a medical student working with the nephrologist today. Can I talk with you about your kidneys?” I started. Excitement in your eyes I later learned you were a teacher. You came to the hospital with difficulty breathinganddizziness,andthiswasn’t the first time. You recollected the struggles you had this past year in and out of the hospital for complications of both your heart and the diabetes. Unfortunately, this time it took a larger tollonyourkidneys.

Going back in the room my preceptor and I had only one plan: dialysis or no dialysis. She looked tired and weighed down, held up only by the hope of her husband and daughter next to her. This retired teacher almost took the words from us, she knew the options. She had been seeing nephrology for years and hoped her kidney function would eventually turn around, but always knew the inevitable. Her husband braced her fortheimpactofthenews.Mrs.KIthink weshouldtalkaboutdialysis andnowI can’tforgetyou.

ThedoctorandItoldyouweneededto prepare for dialysis. We explained the twotypes,andyouchosetherecliner.Are you scared for your arteriovenous fistula surgery? Are you worried this is the end stage of life and not just end stage renal disease? Unfortunately, I don’t need to ask,theanswersarewrittenonyourface, as your eyes gaze down and up to your family.Thelightinyourfacegoesdimand with it the hope in your heart. Did you wonder how this happened? Did you have any regrets? Can you handle the stigma of other’s opinions on your lifestyle choices? You have slowly declined for months now in and out of the hospital. It is difficult for me to imagine what you have experienced in your life with diabetes, heart failure and now kidney failure. I’ve never watched my blood sugar, had my legs swell twice the size, struggled to walk to the bathroom,orlaidinahospitalbedasyou have. I have nothing more to say but stand in the silence. The guilt inside me still lingers after we left you there. An interactionIhopetoneverforgetbecause I know you won’t. I changed your life by puttingyouinthat chair; and I hope if it was me, I would havethecouragetositinthatrecliner. IwishIcouldmeetyouagain.Iwonderif you are doing better now. Was your central venous port put in with care? How was the first time in the recliner? Were you able to schedule for a fistula? But no that is where it ended. I have watched many times the delivery of devastatingnewsinmypatients,butuntil thisoneIhadneverdoneitmyself.Ithink we often forget our own mortality, even when we know the inevitable will happen. Many patients struggle with chronic disease; some carrying more mortalitythanothers.Inthemedicalfield we often see the disease process and stages, but never encompass the full picture of the chronic disease. The physical and emotional injuries our patientsmustendure.

Throughout my time in nephrology, I spent six weeks driving to multiple dialysis clinics. Sometimes 3 in one day. I spent countless hours with my preceptor flipping through papers analyzing and developing treatment plans and checking potassium and calcium over and over. I examined patients sitting in those recliners. I wonder is there anything we can do different to ease this burden for you?

A Moment of Silence

by Analise Diiorio

Astaticvoiceon the intercom shouted, “We have a nursing home resident found unresponsive. Asystole on arrival. CPR started immediately. ETA 10 minutes.” Everyone around me quickly jumped into action to prepare. The afternoon had been slow in the emergency department, and the whole team was excited to jump into actiontoprepareforthearrivalofa critical patient. It was my first day as a medical student in the emergency department. I had not yet figured out how I could best help the team in moments of chaos. Everyone seemed to havetheirnicheinthesescenarios,andit felt like I might disrupt the intricate flow ofthedepartmentwithanywrongturn.I tried my best to be present but also stay out of the way. However, it seemed like everywhere I turned to get out of the wayputmeinthewayofsomeoneelse.

With the blink of an eye, EMS was rollinginthebay.Ourpatientwasalready attached to the Lifeline Arm. Her eyes were wide open and fixed towards the ceiling. Her skin was leathery and gray. She had a single drop of blood falling fromthecornerofhermouth.Thethrust ofthecompressionswastheonlycatalyst causingthebloodtoslidedownherchin. Therestofherbodywascompletelystill. Shelookedalmostdoll-like.Itwashardto believe that she had been alive earlier thatday.

After an initial assessment, she was pronounced dead. Our team crowded around her lifeless body and took a moment of silence. With nearly no informationaboutthepatient,wehadto relyonherbodytotellherstory.Looking at her, I assumed she must have been olderthanmygrandparents.Herhairwas sparse and unkempt. She looked emaciated.

After further examination, the picture becamemoresinister.Itwasevidentthat shehadnotbeenabletocareforherself. HermusclesweresoatrophicthatIcould not imagine her body giving her the strength to move even the smallest of muscles. She looked like she had been sitting in the same soiled bottoms for days. Sores filled her backside. She had evidently been severely neglected at the place she entrusted to keep her safe. I was shocked by her condition. My preceptorexplainedtomethatitwasnot uncommon to have a patient brought in fromanursinghomeinsuchadeplorable condition. Much of the staff in nursing homes work tirelessly every week to treat patients as best they can. But budgetcutsandstaffingshortagescause the patients to suffer the most. My perspective shifted. I could not be angry at the nursing home staff for failing this patient. The problem lies in the medical system at large. How can we as a society let our elders suffer in their time of greatest need? There is not a single person or group to blame. Our national medical system fails this vulnerable populationeveryday.

Ithinkofthispatientquiteoften.Inthe emergency department, we must report the ill-treatment of elderly adults in nursing homes. We hope the complaint findsitselfintherighthandsandpositive changes soon follow. But change is a long,slowprocess.Wehavethegreatest impact on our patients when we treat themwiththeutmostrespectwhenthey come through our doors. Even if our patienthaspassedbeforetheyarrive,we can help bring them peace. We can observe a moment of silence for the deceased. We can change their bedding, clean them up, and designate a quiet, dark room for their bodies to lie while waiting for family or the coroner to arrive. These small notions of respect quicklybecomeapartofourroutineona busy day in the emergency department. However, it is important to do our due diligence for our patients and resist the temptation to go through the motions without thinking of the deeper meaning of our actions. Even with a patient who wasmistreatedbywayofafaultysystem in the final years of their lives, we have an obligation to create a sense of peace and dignity for our patients as their lives cometoaclose.

While physicians in other specialties may not interact with patients in this samecapacity,itisstillvitaltoremember ourroleasaphysician.Wemaynotknow all of the hardships our patients face in their daily lives. However, we have an opportunity to create a safe haven for our patients by advocating for them and treatingthemwithrespect.

6 Weeks

by Alyssa Ferlin

Knock,knock.Afresh third-year medical student enters the room. It’s the last week of her first rotation. She dawns bright green OR scrubs and a white coat with pockets that are visibly packed with papers, a small book, multiple pens, a mini spiralized notebook, and granola bars,whicharenecessarysinceshenever knows when her next meal will be given the chaos that is general surgery. The room is tiny but pretty standard for a doctor’s office. There’s an exam table, 2 chairs, a rolling stool, a sink, and a desk connected to the wall. There are no computers in the room. She notices the rather pregnant woman sitting in the chairnexttothepatient.Theirhandsare interlocked.Beforeaskingaboutonsetof symptoms and where it hurts and what makesitbetterandwhatmakesitworse, she learns a lot about the couple. They are expecting not only their third child but their third girl. She is due 10 weeks from now. He works in security just down the road. He likes to fish. His youngest daughter likes to fish with him, but his oldest daughter wants nothing of the sort. They’ve been married for 10 years. They love their life. They smile big and they smile often. He’s here because ofasmalllumpinhisgroinarea.Ahernia perhaps? He casually mentions a history of melanoma. A 32-year-old with a historyofmelanoma?

He’s rather unconcerned about the history of melanoma. He was cleared a few years ago. He’s young, in-shape, and healthy. Life got busy so follow up with his oncologist wasn’t necessarily a priority.Butthislumppoppedup.It’snot painful; a little bothersome perhaps, and he just wanted to get it checked out. On their way out of the room, there are handshakes, head nods, smiles, laughs anda“takecare,youtwo.”

The third-year medical student goes about her life. The patients she thought aboutdailyandcaredfordeeplyoverthe past several weeks, she’ll probably never seeagain.6weekshavepassedsinceshe met the kind couple in the tiny clinic room for a lump in the groin. Her white coat pockets aren’t quite as full these days, and the green surgery scrubs have beenexchangedforaslickblackscrubset more commonly worn by the internists. At the computers in the doctor’s lounge, she notices a familiar name on the patient list. She reads the notes in his chart like a story book. She’s stunned. Metastatic melanoma. Everywhere. A 32-year-oldguywhowashealthy6weeks agoandexpectinghisthirdchildisinthe intensive care unit. And he’s dying, quickly.

Thethird-yearmedicalstudentwalksup thestairs.Shethinks,whatdoyousayto someone who was seemingly fine 6 weeks ago but is now a frail, dying version of who they once were? The gameplan:getin,giveyourcondolences, chat if they want but keep it short if not, do your physical exam, and be on your way.ButwhentheICUdoorsopen,sheis met with his two young daughters being ushered down the hallway by a nurse. Sheismetwiththeshrillcryandscreams of a 36-week pregnant woman, who just 6weeksagowassmilingeartoearbutis now watching her husband take his last breaths, entirely helpless. 6 weeks ago, sheandherhusbandcrackedjokesabout the cost of the three weddings they’d be paying for 20 years down the road. 6 weeksago,therewereonlysmilesandno tears.6weeksago,lifewasnormal.But6 weekshavepassed.

The third-year medical student feels tears coming on. She is unsure what is allowedinamomentlikethis.Isitbadto cry?Isitokayforhertofeelpainlikethis for people she barely knows? How does she push these feelings aside so she can go see the next patient on her list with a smileonherface?

That night she drives home in silence. She weeps. She weeps for the young wife,whojust6weeksagodidn’thaveto plantogothroughchildbirthwithouther husband by her side. She weeps for the little girls, who just 6 weeks ago were playingoutsidewiththeirdadwithouta careintheworld.Sheweepsforthebaby girl, who will never get to meet her dad. She weeps for the man, who is now at rest,whofoughtsohardtomakeittohis third daughter’s birth so he could hold herjustonce.

The third-year medical student learns that it is okay to feel pain for those she hascaredfor.Shelearnsthatmedicineis not always about curing and fixing people. And she learns, most importantly, that the heart of medicine lies not in the science, but in the human-to-human bond that is formed betweentwopeople.

The Lights Are On, But No One’s Home

by Emily Gansert

Itwasthethirdweek of my neurology rotation around 10 in the morning when my attending and I werefinishingourmorningroundsinthe community hospital. As we filed through the long fluorescent-lit, vinyl-lined hallways, we were urgently paged for a consultation on a patient post-cardiac arrest. With haste, we logged into the nearest computer to learn more about ournewpatient.

On one hand, a thorough review of his chart revealed an average 54-year-old with an uneventful health history until beset by a heart attack early that morning. On another hand, the scans of his brain showed the extensive devastation that his brain endured while only being without oxygen for a few minutes.Hewasseverelybraindamaged, but I retained a small glimmer of hope that our physical exam would elicit something positive, some sign of consciousawareness.

Following my physicians lead, we marchedintothathospitalroomtofindit filled with this patient’s family. We learned about the events preceding this hospitalization and conducted our usual neurologic exam. As we proceeded throughit,wetestedhisvision,reflexes, ability to follow commands, and tone of his muscle. Every stimulation was met with no response. My physician stood facing the family, offering a gentle and comfortinghand,andgavethenewsthat no one ever wishes to hear, that their lovedonewouldnotrecover.

We shared the images of his brain, and explained the disease process that their love one succumbed to in their current state. The physician assured the family that he did not suffer. He wasn’t brain dead, but brain damaged. In a sense, he neitherexistedwiththelivingnoramong thedead.Hisdamagewassevereenough that he would never awaken, but he could remain alive with the appropriate medicalcare.Hisfamilywasperplexedat this thought, to which my physician followedwithhispreferredanalogy,“The lightsareon,butnoone’shome.”Thisis a phrase that everyone easily understands,aphrasethatwillstickwith methroughtherestofmycareer.Asthe words left my attending’s mouth, I witnessed a unified epiphany spread amongst the family about their loved one’s condition and the realization that big decisions would have to be made in thedaystocome.

As I left that room with tears streaming down my face, I now saw life through a new lens. In all my prior brain injured patients, “The lights were on, and someone was home.” This phrase gave the family hope for recovery and that their loved one was still in their physical body. But this was the first time that it wasn’tthecase.Ireflectedonhowweall experience loss and share this as a core human experience. I have experienced loss myself and know of its pain and devastation.Thisexperienceofdelivering bad news showed me what it means to be human, and the heartbreak experienced by families receiving the worstnews.Wealwaystalkaboutputting the needs of our patients first, but what happens when our patients can’t make decisions for themselves? What about theneedsoftheirfamilies?

As a future physician, I will have many roles.Iwillwalkthelinebetweenlifeand death.Iwillbetheretosupport both my best and worst times of their life. In medicine, we are always strapped for time, but I hope we all remember to support and listen to the families of our patients. They are the advocates of our patients, and deserve our time and respect to make informed decisions. There is something special about being heard, and we as physicians are sometimes a family’s only source of knowledge about what is happening. I hopewealllearnhowtoexplaincomplex diseases and tests in a way that anyone can understand. As physicians, we spend more than a decade developing our knowledgeandexpertise,anditwouldbe a waste to not have the capability to share this information in manageable pieces.

Ultimately, our patient was disconnected from life support, had his organs procured to give life to another, and was allowed to peacefully pass on. Despite their heartbreak, our patient’s family expressed their gratitude to my physician for the time he spent with them and the knowledge shared. They were able to process what had happened, understand their options, and make those hard decisions that no one ever wishes to make. They were able to givetheirlovedoneadeathwithdignity, andtheyfoundcomfortinthis.

If anything, my short four weeks in neurology, eight months into my clinical rotations,gavememoreappreciationfor life than any other experience in medical school. It gave me a more profound perspective on the fragile line between life and death, and furthermore, to take nothing for granted. My physician demonstrated extraordinary empathy and compassion to every one of his patients and their families, he took the time to have difficult conversations, and he endowed in me the understanding thatwordscanheal.