Residency Diary: My Second Year: October and November 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.