December 9th, 2006

Nescafe rabbit

Back on Medicine...

The other morning, rounds became a discussion of why everyone should use cocaine. The reason for this, O Best Beloved, is that cocaine users never die. They should - all of their family and friends do - but they never seem to die. They come in with hypertensive urgency, cardiac symptoms, stroke heart failure; we treat 'em and send 'em home. We've reached the point where the attendings know their names as well as the Medicine residents, and it's always a treat when there's a new attending.

One such patient came in the other night, and we were discussing him and his care (back on home meds, counsel to avoid cocaine, watch the blood pressure come down and remind him that his renal failure is only getting worse). The discussion turned to the other cocaine patients we've admitted to Medicine, and we started telling stories.
H was the kind of scary-looking man you wouldn't want to meet up with on the street. He had schizophrenia, heart failure, chronic singultus, psychogenic polydipsia and all sorts of other problems. He had scars everywhere from his trauma admissions. You couldn't understand a word he said, especially after he had his stroke, but the nursing home we'd dismissed him to was less than diligent, and he kept limping out and winding up on the street, where the police would pick him up and bring him to the ER and we'd tuck him into bed and send him back to the nursing home. But you had to be careful about the room you put him in - because he had psychogenic polydipsia. He would, in fact, drink out of the toilet or the sink or any other source of water he could find, dropping his serum sodium to critical levels. And then he'd get hiccups. We had to turn off the water to his room and tape the toilet shut, every time.

This is what I missed about staff medicine, says the attending. I don't have a single patient who drinks out of the toilet.

Also on the floor in recent times: A Mother Superior from a nearby town who has pancreatic cancer and pneumonia; she founded her tiny convent when she came from $country. They appear to be some variety of autonomous Orthodox; they have their own priest and bishops and everything. One day I walked in to see her and discovered that she was about to receive Communion. I stepped right out, but not before I got to see their priest in his full Communion-giving garb. Gold robes, big hat, little gold box around his neck, and he's a white-haired man with a beard to his waist. I wanted to stay and watch, it was so pretty...
Sitting outside the room, I remarked to the nurse that what was going on in the room was far better therapy than what we could give her. You're a cynic. I'm not a cynic. I'm a realist. This woman has recurrent, metastatic pancreatic cancer and that's a death sentence by current medical expectations. I think the Communion has a better chance of curing her than we do.

I met one of the sisters from the convent in the hall one night. I mentioned that I'd heard the bishop had paid a visit. Apparently, he's known the Mother Superior since they were small. "Yes," says the sister. "He's one of the good ones." She slapped her hand over her mouth and looked appalled. It was obligate on me to reassure her that I wasn't offended...the problem with the world is that bad people look just like good people. We talked for perhaps twenty minutes; a loosely-strung discussion about God and platypuses and what it was like to be an $ethnicity Orthodox nun. "Just a dishwasher and floor scrubber. I don't make decisions." And a little bit about dying and losing the woman who'd founded the convent, and what it was like to let go.
You have to watch out, O Best Beloved. Nuns are surpassingly human too.

Our Ukranian gentleman died last night. When I'm 97, if I haven't been to a doctor in fifty years, I'm not going to the hospital unless I plan to die there. Invariably these folks die the day before home hospice takes them home.
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