Hi everyone! I'm a 2nd year resident doctor in an inner city hospital. This is a blog to document some of the experiences I encounter as a training doctor, and some of the things that I learn in the process. After all, being a physician means that I'll be learning some fascinating topics for the rest of my career, and seeing how I can use those to help patients.
Let's get started with today's experience (note, this occurred last year, and I will tell this story in two parts):
Palliative Care
When a patient appears to be devolving into a clinically worse condition, or is actively dying, a major concern is the goals of care, either for the patient or for those who are taking care of the patient (and oftentimes, both). Palliative care, as a specialty, often works with either the patient or their representative to decide upon such goals. This can include whether there is a desire for resuscitation or intubation in case the patient’s condition worsens and may require higher levels of care. Other considerations include blood draws, medication administration, invasive/non-invasive procedures, pain control, etc. There’s a lot that I’m missing here and some is often dependent on the specific situation.
Delays in figuring out goals of care
There are quite a few reasons that delays in this process can occur. Sometimes the patient is incapacitated and cannot communicate their goals of care, and there is nobody else that can be reached for clarification. Sometimes they have a representative who can’t make a decision. Denial of a condition is very common occurrence which can hold up the decision-making process, and is simultaneously unfortunate but understandable.
Another delay includes the lack of a clear diagnosis, thus causing an unclear prognosis. After all, if you don’t know what you’re working with, how can you make a clear decision about the goals of treatment?
Pleural effusions
I have in mind one patient whom I encountered last December, in 2021. Let’s call her Polly. Polly was an elderly lady who had quite a few medical troubles throughout her life, but we managed to find a connection. She was a sarcastic lady and we joked around with each other. By coming to her with updates every day, and letting her know the exact steps in her treatment, I established a trust with her. She would only take my word regarding what was happening, and why. I did my very best to keep my word while going through the bureaucratic processes inherent in my hospital, as well as many others.
Polly had fluid pockets in her lungs which filled up over and over. They caused her a great deal of discomfort and pain. We treated her with antibiotics without success. She had developed pleural effusions, and we did not have a clear cause.
Now, if you briefly read through the link above, you’d see that there are different types of pleural effusions with different causes. The ultimate treatment for each of these is vastly different. Therefore, the only way to figure out how to treat the effusion is to obtain a biopsy of the fluid.
The initial delay of palliative clarification
Here’s where our first problem emerged: in order to obtain a biopsy of the effusion, there needed to be a tube placed into the chest so that the fluid could be drained, and subsequently analyzed. Polly was initially reluctant to get the chest tube, but at the same time wanted her pain and shortness of breath to be treated. It was a Catch-22 situation.
Eventually, we were able to convince her to get the chest tube. The tube itself also caused a great deal of discomfort, and she could not move as much as she wanted to move. In fact, at some points she stated that she wanted the chest tube to come out, but did not initially understand that it would cause all of the fluid to return. She also told us that when all was finished, she wanted to go home, and not back to a nursing home. While this was happening, we also waited for the results of the biopsy and fluid analysis.
As there is more to this story, I will conclude it in the next post, so stay tuned...
I hope you've enjoyed this little snippet of an experience I had as a resident in an inner city hospital. I'll have many more stories and learning experiences coming in the future, so stay tuned.
Sources:
- https://lakesidemedicalcare.com/history-osteopathic-medicine/
- https://www.pennmedicine.org/for-patients-and-visitors/patient-information/conditions-treated-a-to-z/pleural-effusion
- Me 😊
Disclaimer: this blog is for entertainment (and possibly educational) purposes only. This is not medical advice. If you have any questions or concerns about your own health, please contact a healthcare provider.
Here are the previous editions of this blog:
Chronicles of an Inner City Hospital Resident Doctor #4
Chronicles of an Inner City Hospital Resident Doctor #3
Chronicles of an Inner City Hospital Resident Doctor #2
Chronicles of an Inner City Hospital Resident Doctor #1