P is a middle-aged man who speaks only Spanish and has a jumbled history. But his belly hurts, and his lipase is >2000, and he has a gall bladder chock-full of gallstones, so we're betting one got passed to cause him this much trouble. What do we do? We give him antibiotics and fluids, keep him NPO (nothing by mouth) and call surgery, because this man has gallstones like rocks. That gallbladder needs to come out. He's been having pain, we think, for quite some time from them.
The other one would've been interesting - D has a chronic iron-deficiency anemia requiring transfusion today, she's noncompliant with her iron therapy, and she came in with a blood sugar around 500. Not so bad - they've seen 1700 and up in some people - but still interesting.
I'm sending C home today. She's a lady who takes morphine for chronic pain and had her mitral valve replaced because it was so bad it was sending her into heart failure. We saw her for chest pain. We saw her after she'd gotten morphine for her pain, and she was barely speaking, kept drifting off. We held her morphine. We also held her Coumadin secondary to an INR (a coagulation time) that was nearly double what it should have been - and what it should have been is three times normal. Who knows why.
Her chest pain, on exam, was over the scar from where she had her surgery done. It was reproducible - if you pushed, she had pain. Not a heart attack, especially given her negative cardiac enzymes, and so once we got her a little dried up and better coagulated, there was no reason for her to stay here for an inpatient stress test. Especially considering how long it takes to get any but the most simple of tests here.
You learn from hospital to hospital, O Best Beloved. Each one has its quirks and its charms. Here, nothing gets done. There's an unspoken understanding - one that is occasionally verbalized and often joked about - that the care here, despite protests to the contrary, is substandard, compared to a hospital that serves patients and insurance that pays. It takes longer to get things done. Everyone's overworked. The hospital is millions in debt, but if it closed there would be nobody to take the indigent. So if you come here, you'll get the care that will save your life, even the care that will cure you, but because insurance is so often Medicaid or self-pay, you'll spend more time in the hospital and wait for things. It doesn't make sense. If it were more efficient, it would be cheaper to run. We'd have our patients in, echo, cath, and out the next day instead of the next week. But that's just how it works here, and it's a fact of life. Excellent doctors work here, excellent residents train here. We're bogged down in beaureacracy and underfunding, growing cynical and tired with the effort it takes. And that's sad.
Maybe it will change someday. Maybe we'll have the funding to support the volume of patients we see. Without medical students, it would be nigh impossible, I think.
But it's been a light day for me today - P has an admit H&P written already and C has a discharge summary I just had to tidy up for today, and those are our notes for the day - no progress notes necessary. I took a nap for 45 minutes and my headache faded, I passed on Ms. S, the stroke patient with a flutter, to Jim, and then I came to fill you in on the day.
Ms. S is an interesting case - she has a long history of things wrong with her, including possible renal cell carcinoma, a bewildering anemia, and chest pain secondary to aortic stenosis. And she doesn't want any of them worked up. She's here with stroke and atrial flutter now, and she doesn't want anything done, but her family wants everything done. And it's her right to die with dignity.
When you see a code run, O Best Beloved, it makes you wonder. When you see the outcome of so many of these codes on elderly people, it makes you pause. When I am old, I think I might be a DNR. I want to die with a little dignity, when God decides it is time, not to become an automaton surrounded by machines and tubes, more android than human. I want to be allowed to die at some point. I do. We are mortal. We were made to die. And I am not afraid. I have seen death, held its hand as it slipped its shadow over a fragile frame. I have touched it, felt its coldness and left a piece of my soul in its tender grip. I am not afraid of death, O Best Beloved. I am afraid of being roughly torn from life, violently or brutally ripped away from all that I love and cherish. I am afraid of that, a little, and I am afraid of leaving things undone. But I am not afraid of dying or of what lies beyond. And when it is chosen for me to die, I hope, O Best Beloved, that those who love me are also not afraid.