Even though it was only the second week of the Infectious Disease sequence, people were already beginning to get a little tired of the routine. Each morning started at 8am with 2 ½ hours of lecture with a small group session following directly after. Despite the “Groundhog Day-esque” feel of our days, I, for one, had come to enjoy the predictability of my mornings. Stability of any kind isn’t easy to come by in medical school, so whenever I find some, I consider it a gift.
Seven months into the year we had completed our first “sweep” through the entire human body. Covering each body system in turn, we’d spent our time learning what happens when the body is running like it’s supposed to.
ID represented an important shift in our education. Starting with ID, and continuing second year, the focus shifts to pathology–what happens when something goes wrong in the body. Even though it was early in the sequence (it’s one of our longest at 5 weeks), I liked ID so far. In small group, we focused almost exclusively on clinical cases. We spent time going through each clinical scenario one by one and discussed potential diagnoses, treatments, and preventative measures associated with the case.
When we were first presented with these cases, I had the unmistakable feeling that I was working to solve some kind of puzzle. A word search maybe. The answer was always right there in front of you somewhere; it was just a matter of putting the clues together. This particular day’s case was no different:
“A 72-year-old man who lives in a long-term care facility and who has had an indwelling Foley catheter for several months and chronic renal failure with a creatinine of 2.1 mg/dL, develops confusion, temperature to 101.2 F, and is brought to the emergency room. On physical examination, the patient is toxic, febrile and confused. He has what appears to be CVA tenderness on the right. His urine is cloudy and shows too numerous to count (TNTC) WBCs, 5-10 RBCs, and 3+ protein. His creatinine is increased to 3.1 mg/dL and the BUN is 75 mg/dL. Urine culture is obtained and the lab tells you that the urine is growing >105 lactose-positive gram-negative bacilli.”
There was a lot of information being presented and I did my best to quickly sort through all the “clues” being given. I skimmed through the questions that followed and attempted to draw some conclusions of my own (in a minute or two, we’d go over the answers as a group).
Why did the patient develop a UTI?
Catheter probably had something to do with it.
Why do you think his creatinine is rising?
First thought: his kidney is cranky
Second thought: Acute tubular nephritis (a regurgitation from lecture).
Why did the urine grown Enterobacter cloacae instead of E. Coli?
Are there any worries about which antibiotic should be prescribed because of the specific organism that has grown in culture?
Even better question.
It was clear I had a lot to learn. But even though I didn’t have all the answers, it was still exciting to work through the puzzle of the diagnosis. As we thought through causes out loud, formed differential diagnoses and reasoned out treatment strategies, I reveled in the newness of what we were doing. When you think of training to be a doctor, you don’t necessarily think about memorizing biochemical pathways or spending hundreds of hours watching lectures. No, this was different. For the first time, we were actively learning how to think like a doctor thinks.
How cool is that?
After finishing up each of the clinical cases for the day and going over some basic lab techniques, it was time to call it quits. When the day’s session officially came to a close, I lingered in the classroom a bit to talk to friends. Then packed up my things and headed home to study. And I’d do it again the next day.
Stability. It meant that tomorrow, I knew exactly where I’d be and what I’d be doing.
But here’s the thing about predictability: it’s almost always a false sense–even if we like to comfort ourselves by thinking otherwise. As for me, I had to be reminded the hard way…
It started off simple. At around 10 pm, I caught a chill. Nothing big—I just couldn’t seem to get warm for the life of me. By 10:30, I was shivering and my stomach started to feel…well, “funny” (that should be an official medical term in my opinion by the way). At first, I brushed it off, thinking of any and every alternative explanation (read: differential diagnosis) for what I was experiencing. I assumed that the early morning lectures and lack of sleep were finally catching up with me. I figured it was something I ate and I just needed to wait it out. I thought a lot of things; but I certainly didn’t think that by 1:30 am, I’d be in the emergency room.
But I would be—because by midnight I was weak, my head was swimming, and my stomach…well, I’ll spare you a particularly graphic recounting of those details, but suffice it to say that it was like every ounce of fluid in my body simultaneously decided, “Yeeaah…so…I don’t really want to be here anymore”. What can I say–I felt. Like. Hell. Still, it was a friend who urged me to go to the ER rather than a plaguing sense of self-preservation. In actuality, something made me hesitate before seeking medical care. Maybe it was a childhood fear of the doctor’s office resurfacing at inopportune time. Maybe it was the more reasonable fear that the bugs I could catch at the hospital would actually make me sicker instead of better.
Or maybe, the truth was much more complicated and uncomfortable. Maybe the truth was that somewhere in the back of my mind, I thought I shouldn’t have been sick…couldn’t have been sick. Because being sick is a patient’s job, not mine.
Othering–a process of separating your identity from the identity of another and in doing so, avoiding the stigmas associated with the “other”. Seems to me it all boils down to the creation of distance—and that distance, in and of itself, is neither good nor bad. It’s both.
We are simultaneously implored to connect with patients emotionally and to not be overly moved by emotion. We are to get close, but not too close, and as a result, we draw boundaries in the name of professionalism. We divide us from them. Sick from well. Healer from healed. The million-dollar question is, where do we learn it?
I can’t pinpoint the source, but someway, somehow, it’s being taught. Want proof? I haven’t set foot on the floors and yet already I’m beginning to learn it. Without question, there is something invisible and persistent shifting my vision. The shift is slight now—no more than a slight blurring at the edges of my perception—but it is enough to make the reality of me being a patient feel…unnatural.
In any event, it was with a weary sort of acceptance that I offered up my arm to the ER nurse so she could take my vitals. The numbers weren’t great–I was definitely sick. Afterward, she shuffled me to a small room where I’d end up spending the rest of the night. I shed my pjs and quickly changed into the oversized gown they’d provided. Swallowed by the material, I felt small…and even smaller when they hooked me into a line and filled it with a drug I hadn’t learned about yet. Some time passed, and then a doctor came in to exam me. I recognized that she was giving an abbreviated version of the abdominal physical exam. We’d practiced it just a few weeks ago. It was something recognizable—and put me oddly at ease, at least for the moment. But then she was gone, and I was left alone.
In the quiet of my room, I wondered at my situation. Just the other morning I was in class, studying, living out a normal day. I never thought that in less than 24 hours I’d be in a hospital bed. It occurred to me that most people who end up in the hospital don’t plan on getting sick. They’re living out their “normal” days too, and then illness comes along and shatters their routine out of the blue. Sometimes, forever. How’s that for unpredictable?
The night passed slowly. I had to get up a hundred or so times to run to the small bathroom at the end of the hall. Trust me when I tell you it was a torturous procession—first, I had to unhook my IV bag from its post and hold it up in the air to allow the fluid to keep flowing. Then, I had to make sure the tubing wasn’t twisted, kinked, or just plain wrapped around my person. Also, leaving my room meant seeing other human beings and I was relatively certain that they wanted to see me exposed even less than I wanted them to see me exposed. Waddling down the hallway, with one hand holding the IV bag up and the other holding my gown closed, I felt like one of those contortionists at the circus (except I didn’t have the benefit of a leotard–which by my estimation would have provided better coverage than that darn hospital gown).
By morning I was feeling much better; not 100%, but well enough to be discharged. I certainly couldn’t have been happier. I spent several days afterward recovering (from what proved to be the worst illness I’ve ever experienced) and eventually had enough energy to return to small group. For my unceremonious return to the land of the living, I was greeted with a new clinical case. I skimmed for the highlights:
“A professor who was born in India returned there to lecture for a month…12 days after returning to the U.S. he had chills and fever that progressively became higher, myalagias, anorexia, and abdominal pain. In the ER, he said that he felt awful and seemed confused. His temperature was 103 F, pulse 60…..”
Although everything in small group was the same as when I left it, I stumbled a bit before dropping into business as usual.
Today, the “puzzle-solving” would have to wait; because now, instead of focusing exclusively on the differential diagnosis, or the source of infection, or the treatment plan, my mind clung to one sole conclusion as I rescanned the patient’s awful symptoms:
…This guy must feel. Like. Hell.