Patient Care CEO 1.
- Approach the care of patients as a cooperative endeavor, integrating patients’ concerns and ensuring their health needs are addressed.
- Comprehensively evaluate patients by a) obtaining accurate and thorough physical examinations; c) gathering detailed ancillary information; d) synthesizing all relevant data to generate prioritized differential diagnoses and e) formulate plans of care that reflect an understanding of the environment in which health care is delivered.
Besides helping us learn, stories are helpful in in shaping experiences into knowledge. The stories that have emerged with just a few rotations preview what will become lessons and learning for my lifetime. One story comes from early in my third year of medical school. It was late in the day during my hospital pediatrics rotation. I heard the new patient’s inspiratory stridor down the hallway even before I saw him. My resident and I examined him and took a history from the parents of this ill, little four week old boy. His father worked in sales; his mother was a nurse. Both were extremely worried. Her pregnancy was uncomplicated, with good prenatal care, and the patient had been delivered at full term. He’d been kept in the NICU a few days for poor oxygen saturations. Since then, he hadn’t been able to regain his birth weight, despite his mother feeding him every two hours with 2-3 oz of pumped breast milk that had been enriched with extra calories per dietician recommendations. He made a good number of diapers a day. There was no family history of illness. His oxygen saturations were still poor. On examination, he was thin with suprasternal retractions. Otolaryngology soon came around with a flexible laryngoscope and confirmed what I suspected: laryngomalacia.
I already understood pieces of this young patient’s problem. As a part of the ENT Extracurricular Elective, I had given a talk on laryngomalacia to the rest of the group. Figure 1 shows the physical models I made for the talk. I knew laryngomalacia was the most common cause of congenital inspiratory stridor. Most children outgrow it, but in some, it be can severe enough that the infants waste so many calories struggling to breathe that they develop failure to thrive or other complications. I had already seen less-severe cases of laryngomalacia, which could be managed with observation. This patient, however, required supraglottoplasty, a surgery to divide the aryepiglottic folds to allow the epiglottis to spring back into proper position. With the epiglottis less constricted, the work of breathing would decrease, and more of his calories could be used for putting on weight the way an infant should.
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Figure 1: Hand-made paper laryngomalacia models.
His mother was terrified that he would need a tracheostomy. Due to my study of the topic, I was able to reassure her that virtually no laryngomalacia patients need tracheostomies these days and that supraglottoplasty is a safe surgery with excellent outcomes and few complications. She was very relieved.
Figure 2: Laryngomalacia PowerPoint.
I checked with my residents and the attending of the surgery, and I was able to watch the surgery. The difference I heard in his breathing was immediate. While the stridor was still present, it was much quieter, and he physically appeared to be breathing more easily, without suprasternal retractions. He spent the night in the PICU before coming back to our floor for monitoring to make sure he would start gaining weight appropriately. His tired mother told me how she was frustrated that the PICU gave him Heliox, a low-viscosity mixture of oxygen and helium used for patients with airway obstructions, even though his oxygen saturations post-operation were better than they had ever been. She felt like they were just hearing that he was still stridulous and treating it without taking into account how much less stridulous he was now compared to where he had been. I will keep in mind that families want their loved ones to be treated as whole people, not collections of symptoms.
Over the next few days, he started to gain weight. I went with him to his echocardiogram, which had been ordered to make sure he did not have any undiagnosed heart defects that could be contributing to his clinical picture. His echocardiogram came back without evidence of any such defects, to the relief of his parents. I was there with him on my last weekend on that service, and his parents expressed concern. With changes in staffing, new clinicians who saw their son were always alarmed by his continued stridor, even though his stridor was much improved, and he was gaining weight. His mother looked forward to soon being able to breastfeed him directly, instead of having to pump and add in extra calories. From the start, I had been there to see his clinical improvement, and they were worried that, without me around as a touchstone, he might be subjected to unnecessary testing, when the etiology of his condition – laryngomalacia – was already well-established, and his failure to thrive was resolving. I reassured him that whoever saw him would give the best care possible and that his hospital course to date was well-documented.
This story had a happy ending with lessons that I’ll remember. Still, I wish I could have stayed with him for the rest of his hospital course, instead of moving on to another rotation. I look forward to continuity of care as an attending and seeing my patients through their roughest patches.
My second story again touches on continuity in care but with a new wrinkle – the importance of seeing some problems through fresh eyes. I found some of that continuity on my psychiatric rotation in Harding at the end of my 3rd year, where I could see patients throughout their entire hospital stay. One of my duties was to find patients and bring them to a meeting room for their daily chats with the attending and the resident. There were two medical students on the service, and we usually brought out the patients we had been following. However, one day, the other medical student was away. I went to find a patient he had been seeing for almost a week now.
The whole time, the patient had been complaining of pain and anxiety. She had a past history of opiate and benzodiazepine addiction related to over-prescription of inappropriate opiates and benzodiazepines. Now that she wasn’t on those medications, it was only expected that she might complain of pain and anxiety. She had been placed on scheduled, round-the-clock Tylenol at its maximum daily dose, and she had been urged to attend the group sessions and work through her issues.
She also had a history of borderline personality disorder. Unfortunately, she had been previously misdiagnosed with bipolar disorder and had been treated unsuccessfully for bipolar disorder for several years. She resisted the shift of her diagnosis from bipolar disorder to borderline personality disorder. Her resistance was understandable; all mental illnesses unfortunately carry stigma in our current society, but those patients with borderline personality disorder are often specifically dismissed by healthcare providers as chronic complainers. Patients want to be treated with respect and dignity and will resist diagnoses that they think will lead to poor treatment. Yesterday, we had given her more information about borderline personality disorder and dialectical behavioral therapy, the best treatment available to date for borderline personality disorder.
As I approached the patient’s door and told the nurse I was looking to bring the patient to her daily meeting, the nurse warned me with a slightly sarcastic, “Good luck.” I entered the room and immediately thought that the patient looked sick. She was huddled up under a blanket and shaking. She felt warm to the touch. She wasn’t as talkative as usual, and she didn’t want to attend her daily meeting. I asked if I could examine her and noticed a warm red rash around well-healed surgical scars on her abdomen. She agreed to let me trace the rash with a pen, so we would know if the rash changed size.
I came out of the room and checked again with the nurse, who had just taken vitals that were more recent than the last set I had seen. The patient had just broken a fever, and she’d missed her last dose of Tylenol, being too tired to take it. I went immediately to the attending and resident and explained the situation. They went with me to see the patient in her room and agreed with me: the patient had a post-op wound infection. It was about three weeks out from her hysterectomy, which was an unusually late time frame for a wound infection to appear, which was part of why the infection had gone unsuspected. By giving her Tylenol around the clock, her fever curve had been suppressed. She’d been anxious and in pain, but we’d expected that. Only when she’d been too tired to take her Tylenol had her fever been able to manifest. We could have missed her wound infection entirely, dismissing her aches and pains as being related to her past history of opiate and benzodiazepine and psychiatric illness.
My psychiatry attending had me consult Ob/Gyn to immediately come see the patient, which they did several hours later. By then, the extent of the rash had spread beyond my initial pen marks, which the Ob/Gyn resident found very helpful to evaluate the progression of the infection. The psychiatry resident had just started this rotation that day. While the other student had been seeing her, I was still more familiar with her medications, which had been fine-tuned and optimized for days, than the psychiatry resident was. The psychiatry resident had me go through her medications with the Ob/Gyn resident to make certain that she would receive all her medications correctly while she was admitted to the Ob/Gyn service for treatment of her infection. I also mentioned to the Ob/Gyn resident about her history of opiate and benzodiazepine addiction, which he appreciated and promised to keep in mind in balancing the need to treat the pain of her infection with her future continued health.
One important takeaway from this case is that psychiatric patients absolutely suffer all the same illnesses as everyone else. Attributing all symptoms to one cause feels neat and tidy, but sometimes, patients really do have more than one etiology for their symptoms. Moreover, simply attributing all symptoms to psychiatric illness can lead to lingering, untreated pathologies, healthcare inequalities, and disparities. When I was on cardiology on the acute coronary service, I saw a patient who had a history of anxiety be given extra Versed for anxiety when her blood pressure spiked instead of antihypertensive medications, despite the fact that she had just suffered a myocardial infarction. The team thought her hypertension was just anxiety. When the blood pressure wouldn’t come down with Versed, they finally gave her antihypertensive medications several days later, which promptly brought down her blood pressure. To avoid this type of medical myopia and injustice, clinicians evaluating psychiatric patients need to think, “But if these symptoms weren’t psychiatric, in this context, what would they be?” to make sure that they don’t miss an untreated condition.
Interestingly enough, this story has another twist. After we had recognized the wound infection, the patient said that she wanted follow up dialectical behavioral therapy after she recovered from her infection and wanted to make sure that referral didn’t get lost in the shuffle. It finally made sense to her why the treatment for bipolar disorder had never helped her. She didn’t have bipolar disorder; she had borderline personality disorder, like we’d been saying. It was as if acknowledging her problems with respect and dignity had led her to extend some trust back to us.
The psychiatry consult service continued to see her while she was treated for her wound infection, and she did well. Perhaps it was good for her that the medical student who had been seeing her wasn’t available that day; I came in as a fresh pair of eyes to provide a different perspective on her situation. I received this evaluation of my performance during my psychiatry rotation:
Figure 3: Psychiatry rotation Curricular Unit Narrative and Comments.