Tuesday, March 9, 2010


Status-post second day as a third-year medical clerk, and never have I been so conscious of time as a limited resource. There's not enough time in the day to see enough, read enough, eat enough, sleep enough -- even pee enough. Even when I have "free time" to do things reminiscent of My Old Life (the one from two days ago), I don't do them. Something's different.

"They" told us that everything becomes different now. All that matters is "our patients" -- the ones that were mentioned so infrequently during Orientation last week that I actually forgot (for at least a few hours) that I'd interact with any. Then, you show up and get thrown into this crazy, chaotic world of beeping alarms and White Coats walking around and spitting out numbers, minimizing human interaction wherever possible. The detachment is palpable.

A few hours into my day yesterday, though, I was told about a new patient coming into the Emergency Department after being sent in by his doctor urgently after discovering insanely elevated blood levels of potassium and creatinine. I was told he'd be "my" patient, and was later told to show up at the ED and interview "the guy in A8." I've gone into rooms to interview patients before: I could do this, I figured. So I found my way through the labyrinth of my new world, walked right in, sat right down, and... everything became different.

Over the past 36 hours, "the guy in A8" really has become "my" patient. I arrive at 5:30AM to check on all his labs and examine him. I present his updates to my team. I write up notes for his chart, write medication orders (seriously?), and spend most of the day with him and his family. I pop into his room periodically to give him "life updates," as I call them - what's going on with various tests, medications, and how the team is thinking about solving his case at x point. Because you know what? NOBODY ELSE IS.

"Be careful about giving patients too much information," cautioned my intern today. "You might make them anxious."

In addition to textbook resolution of his hyperkalemia, my patient was given insanely high-dose IV steroids yesterday to treat his mysterious kidney disease (which, in actuality, may be something that House throws out on his differential every episode but that we were taught in school that nobody actually gets...). Today, the team suggested adding another insanely potent immunosuppresent: a cancer drug, cyclophosphamide. Silly post-USMLE Step 1 jaw-jerk reflex goes off about the only thing I know about cyclophosphamide: that it can cause fatal hemorrhagic cystitis, and should be given with another drug called Mesna to inactivate its dangerous metabolite. Shot down. Silly med student. I pushed the issue with two interns, an attending, a pharmacist. I'm paranoid that this was my one opportunity to be useful, and I couldn't "sell it."

"So, we're going to start a new drug on you," says the intern to My Patient. I shudder. We're just going to do x to you. Not 'recommend.' No 'what do you think?' - no 'is this ok with you?'
"What is it?"
"It's a drug that shuts down your immune system."
"What's it called?"
Patient's wife (a nurse)'s eyes bulge out of her head. I instantly detect that she recognizes the drug name and thinks that her husband has cancer, and that we're not telling him. I try to intervene. Intern obfuscates with vagueness. My patient interrupts.
"Do I have cancer?"

Finally, it occurs to me how to explain that different drugs are used for multiple purposes. Everyone quiets down. But I deeply regret those 2.5 minutes where these lovely people felt in the dark about their lives. There was no need for it.

I continued to obsess over it, until I alleviated my hang-up by finding an article that documented that cyclophosphamide is the standard treatment for what we think he might have. I printed it. I don't know whether they cared what it said. But I did know that they cared that I knew they were scared and confused.

Tonight, it's time to leave. I tell the intern that I'm going to tell my patient that his cyclophosphamide first dose is coming tonight. That's when I was cautioned about the perils of keeping people informed about the whats, whens and whys of introducing toxic cancer drugs into their bodies, without thorough discussion of side effects. I did it anyway.

"Am I going to have to take this forever?"

I can't protect my patient from his kidneys or his medicines, or the cold alienation of his surroundings. I don't know whether my presence in his room contributes any real difference. I've never wanted to fix someone so badly. I hang onto his every little detail that comes out of his mouth, hoping that I'll catch some subtle little detail that everyone else blew off. I exaggerate the things I hear. I've been reading for hours about reactivated rheumatic fever. Nobody gets that. But then again, nobody gets what everyone thinks he has...

People say that the value of the third-year medical student is how much time we have. Unlike actual doctors managing dozens of patients, all of my energy and cognitive resources are invested in one man. I technically have oodles of time to indulge my tangents. But when you think about a round, little old man lying alone in a hospital bed -- caught in a balance between his kidneys trying to kill themselves and the toxins we gave him threatening to kill him first -- there's never enough time in the world.

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