1 day in 7

I am two weeks away from finishing my internship in preliminary medicine at the University of North Carolina.  Around Christmas time I was on the cusp of quitting.  In my previous post I stated that being an intern is like being "a busboy" or maybe a waiter of some sort, carrying out orders, being swamped with paperwork, working long hours, and generally being underappreciated. I was jaded with the system, and skeptical of inpatient medicine after observing patients suffer from iatrogenic harm from moderately invasive tests I ordered... 

I finished this year, and I have so many stories to tell but no one to tell them to, so I will post them to my blog which has many faithful followers.  I get one day off every seven, so on this Sunday which I am off, I will recount one of these stories briefly because everything seems better and humorous in retrospect.

Like the time me and my senior resident were in the ER examing a forty something year old Nigerian woman who I will refer to as Sheila. She had weightloss, diarrhea, productive cough, myalgias, and fevers for a month and had been to Nigeria 5-6 months prior...  The next morning I presented her story on rounds, and about 2 minutes in, my attending physician interrupted me and said, "has she been tested for HIV?" 

"Yes, the ER sent this off," I replied (in my head I was not sure though).  After rounds I headed straight for a computer to see the results from Sheila's labwork, but my attending physician beat me to it and said "her HIV test came back positive." And then I felt relief. We have an answer, we have a source and we can treat it. The day rolled on and by around 7PMish, it hit me that I still had not told Shiela her diagnosis.  Soon it would be time to sign out to night float, and it would be inappropriate to have someone who had never seen this patient break the diagnosis to her. So I put on the yellow contact precautions gown, wore my N95 respirator (as this patient was being ruled out for C difficile colitis and tuberculosis), and I updated my patient.  My voice was soft and nasal as the respirator was pinching my nose.  I had forgotten everything I had learned in medical school about delivering bad news.  I was relieved to have a diagnosis and an answer; Shiela's torment was just beginning.

Sheila burst in to tears... I wanted to give her a hug to console her, but she was too weak to get out of bed. And then it hit me how isolating it must feel to be handed a diagnosis like this from a virtual stranger. I would leave and go home that night, but Sheila would be alone, confined to her room with only her racing thoughts. The following day we started prophylactic medications and consulted the infectious disease specialists. Eventually Sheila informed her husband of her diagnosis.  I tried multiple times to call him to encourage him to get tested. When I finally was able to get ahold of him, his reaction was complete denial. 

With time, IV fluids, and broad spectrum antibiotics, Shiela eventually got better. She was started on anti-retroviral medications, and her husband had setup an appointment in the ambulatory care center to get tested for HIV as well. So there are happy endings during intern year, it's just so easy to forget about them.

Back to the million dollar question: What's next for me?

That I'm not certain about.  People have referred to neurology as a form of "intellectual masturbation" where a complex thought process goes in to diagnosing a condition which can't be treated. As a resident on the neurology wards service, I understand that by and large the intervention for ischemic strokes are conservative and far from heroic. The patients in the epilepsy monitoring unit usually have psychogenic pseudoseizures which generally don't respond to medications.  But maybe one in seven patients get significantly better because of our interventions and treatments.  Like the patients with myesthenia gravis who get plasmapharesis and regain their strength. Or the patients with giant cell arteritis who receive high dose steroids thereby saving their vision. 

So for those one in seven people, I'm going to ride this out I guess.