Somehow I have gained a reputation in residency as being the person who is "too nice." My coworkers often criticize me for accepting "soft admits" and filling the service with patients who should be discharged from the ER. Whether or not this is true, it makes me think back to February of my intern year when I discharged a difficult patient from the internal medicine service.
He was a 60 year old man whom I will refer to as Mr. Winters who had irritable bowel syndrome. He was admitted with intractable abdominal pain. The details are somewhat hazy as it has been a few years, but his workup included a CT abdomen/pelvis with and without contrast, an upper and lower GI endoscopy with biopsies, all of which were "stone cold normal." He was having normal bowel movements and tolerating po. Our gastroenterologist essentially gave him a clean bill of health from a GI perspective.
In spite of this, poor Mr. Winters continued to have severe abdominal pain. On morning rounds the decision was made to discharge Mr. Winters as there appeared to be no dangerous medical cause for his abdominal pain. He lived at home by himself and he had expressed anxiety in leaving the hospital.
Somehow I had gained an uneasy rapport with Mr. Winters because I spent over 20 minutes of my time to listen to his history. It is unusual for residents to spend more than 5 minutes talking with patients after an initial history and physical has been taken. He told me about his time in Vietnam. He reportedly had to be admitted to a hospital there when he had intractable seizures. When he returned home, his family relationships were severely damaged. He seemed to hint that he had an extramarital affair in Vietnam, and that ended up alienating him from his wife who left him and his daughter who could not forgive him. Again the details are hazy, but what is certain is that poor Mr. Winters had no family, lived alone, and still reported severe abdominal pain.
Later in the afternoon when I was making arrangements to discharge him, he was on the floor writhing in pain. He did not want to go home and be by himself. I called his daughter who seemed exhausted and upset with her father. Ultimately, one of his neighbors and close friends also expressed reservations to releasing Mr. Winters; but agreed to spend time with him and drive him home. Mr. Winters was upset that I was discharging him. He still was writhing on the floor with abdominal pain. He asked me what he should take for his pain. I told him tylenol. In retrospect that response seems callous and cruel. I didn't want to commit the cardinal sin of intern year, which is hospitalizing patients who do not meet inpatient criteria.
One week later I was reviewing charts and saw that Mr. Winters had found his way back in to the ER with a tylenol overdose and suicide attempt. For a brief moment my heart raced and I was nauseous. I felt a pang of guilt, but only briefly. The plans for discharge had been discussed with my senior resident, attending, and gastroenterologist, and I was following through on what we all agreed on.
One week later I continued to care for Mr. Winters when I moved to the psychiatry service. His abdominal pain seemed to take a back seat to his suicidal depression. In fact, he stopped complaining about the abdominal pain altogether. He spent more time discussing his sense of worthlessness and discussing how everyone had turned their back on him. His wife, his daughter, his doctors, all seemed to have abandoned him in his mind. The only thing that became clear to me at this point is that if Mr. Winters went back home alone he eventually would succeed in killing himself. Arrangements were made for him to go to an assisted living facility where he would have a roommate and nurses to give him his medications. We spent 2 days preparing Mr. Winters for this plan and for discharge.
And then it was deja vu. On his day of discharge, he said he was not ready to leave. He complained that the food at the assisted living facility was crap and would not agree with his irritable bowel syndrome. He looked at me with pleading eyes, and begged not to be discharged on morning rounds with my attending present. But I gave my cool and by now rehearsed response. I explained that at this point there is nothing we are offering in the hospital that can't be done elsewhere. We have made arrangements for him to have the resources to continue his care in an assisted living facility. He could always call our 24 hour psychiatric resource line should his depression reach suicidal levels.
He was livid. He called me a traitor and a fraud. And then he was escorted out of the hospital by security.
On my 1 day in 7 off, I went to visit Mr. Winters in his assisted living facility one week after discharge. (To be fair, I actually had 2 day weekends on psychiatry). He was pleased to see me. He offered me an apology for the terrible things he said to me, and then told me that I was one of the few people who cared. He was visited by his brother who is a retired physician and had left some detailed instructions on his diet. Surprisingly, he had grown fond of the staff at his living facility and the food that they served.
I did not lose much sleep over Mr. Winters. Some people have illnesses that can't be cured or managed by pills. I will say that Mr. Winters has my sympathy. I'm not sure if I believe in the diagnosis of irritable bowel syndrome, but I know and understand what severe depression can feel like, and his problems were amplified 100 fold by his alienation from his family. I hope he continues to do better.
