Prompt: A clinical event I hope I never forget
This is a hard one for me to decide on. There are two
experiences that I hope to never forget, and they each pertain to one of the
two specialties that have seriously vied for my career. I will begin with the
most chronologically recent.
In November of 2015, I was on my first of two months of
inpatient IM, specifically on the cardiology service at Froedtert hospital. I
had been there for three weeks already, and was getting pretty comfortable with
the team, the workload, and perhaps inpatient medicine in general (something
that I thought would never happen based on my mediocre experience on inpatient
pediatrics). For my very last week, I decided to take on a new patient—an ICU
patient. I had avoided following these patients before, as they understandably
entail a great degree more detail, and I was ever afraid of bombing rounds by
missing these details or just not being able to keep track of everything. This
patient would turn out to the most significant patient—indeed, life saved—that
I would encounter during my M3 year.
Mr. L was a 36yo M who bizarrely had a STEMI the week prior.
He had been cath’d and stented at the WI heart hospital, though there was
seemingly no reason for the heart attack—his cholesterol wasn’t great, but
wasn’t at the level of a familial hypercholesterolemia. He was a non-smoker,
was physically active, highly productive and was married with two kids. I
mention those last two because they tend to be poor prognostic indicators.
While at home, Mr. L had suffered a potentially lethal
arrhythmia. He “went down” in his kitchen, the event being witnessed by his
wife who called 911 and began CPR. It had been approximately 6 minutes before
EMS arrived and converted him to sinus rhythm. He had developed VFib.
When he came to our service, Mr. L had been placed under a
hypothermia protocol. His neurologic status was unknown—the doctor performing
his diagnostic cath on arrival thought he had been in decorticate posturing.
The nurses thought he had clawed at his intubation equipment. Nothing would be
known until 72 hours on hypothermia, and weaning of sedation. Things were
looking grim. My attending told me that only 18-21% of in-hospital events requiring CPR survive to discharge. I already
knew the numbers for out of hospital were many times worse. Mr. L’s wife never
left his side. His mother and father were there. Things were set to be the
first real tragedy I experienced up close, with one of my patients.
The day of the weaning began. He was brought back to normal
temperature. His sedation was to be reduced by the critical care team. He was
on my mind all morning, even after talking about him on rounds. I went by the
room later that morning and saw perhaps 20 people in the room. Oh shit, I
thought. But when I stepped inside, the atmosphere was not as somber as I
expected. There were tears shed, but it became quickly apparent that they were
tears of joy. I approached the bedside where Mr. L quickly looked up at me from
his wife. He had regained full neurologic function.
The climax of the story ends there. His subsequent course
was not simple—he had another episode of VFib hours later, but was immediately
shocked back. He received an ICD. His twin
brother also presented to our ED with complaints of chest pain, which we
ruled as stress cardiomyopathy. But I’ve never seen, at least first-hand, a
case where a highly functioning patient has come so close to death or permanent
disability, and was given a second chance at a long life thanks to medical
advancement and quick thinking.
My second experience is a little more grim, but a little
less emotional all the same. Right before I started my IM rotations, I had
begun a 2 week pathology elective rotation. Pathology has been the field I
wanted to enter since I was in college. I love the idea of retaining my basic
& cell biology. I wanted to work in a lab, like a proper scientist. My
pathology lecturers were always the best organized, and the most knowledgeable
about the pathophysiology of the diseases we learned about. I still admire and
respect them.
The thing about pathology is that it’s very different than
the sort of medicine that you are trained to practice during medical school.
Gone are the needs for history-gathering, for physical exam skills, even
arguably for a large degree of meticulous documentation. It is so different
that the program directors have told me to “be prepared to be worthless” come
first year of residency. So, I spent the first several days in what amounted to
a shadowing role. Sit in on sign-out, on grossing, on frozen sections. Though a
lot of it was over my head, I could tell from the atmosphere and the way things
moved that this was the career for me. At least, that’s what I told myself. The
single crystallizing moment that cemented my decision to pursue pathology was a
couple of cases which were assigned to me by Drs. Brian Hunt and Matthew Stemm.
These cases were probably previewed and straightforward, no
doubt, but nevertheless it was the first time that I had been left on my own to
try my hand at rendering a diagnosis—a pathologic one, anyway. All I had at my
disposal, in a world that was admittedly very foreign, were two slide trays, a
pilfered microscope, my lone pathology textbook, and a login to Epic. I was
frantic at first, eager to get the answer right to impress a pair of doctors I
respected very highly. But I had no idea what was going on. What were those
cells? What does this architecture mean? I had to calm down and go to the
patient’s clinical history. The first case was a pancreatic mass on imaging. It
had been sampled by ERCP and needle biopsy, then smeared (hence its delivery to
the cytology service). There wasn’t any architecture at all. The options
narrowed. Ductal adenocarcinoma? Acinar cell? Pseudocyst, abscess? I had never
seen what these looked like. But the basics I had learned during my preclinical
years came in. These cells had atypia. I found some mitoses, several per field.
The cytoplasm looked bizarre, compared to the normal histology in my textbook.
They didn’t stain for the markers that I would expect of acinar cell. I made
the call—ductal pancreatic adenocarcinoma.
The second case went similarly. Thoracentesis, concerning
for malignancy. The fragments of tissue that remained had distinctive shapes
and associations with one another. The clinical history again directed
me—history of bladder cancer. Now that you mention it, those clusters of cells do have the look of a transitional epithelium about them. Would mesothelium stain as basophilically as this? I made the call again--metastatic urothelial cancer.
I got to present my cases to Dr. Hunt at sign-out. I used far too many words to convey what a resident would do succinctly, and had probably poor insight into my diagnostic reasoning, but nevertheless, he agreed with my diagnosis. I had gotten my first pathologic diagnoses right! The doctor was less eager than I was to hand down such dismal reports. He was far more methodical. He had seen all of the other possibilities it could be and weighed them all heavily. He was not as easily swayed by the clinical history--a valuable trait, as a pathologist's reports need to be as close to objective and absolute as possible (pathologic diagnoses are usually considered gold-standard, and minimizing bias is therefore essential).
These have been the most salient experiences for me these past 6 months. Whoops, only 30 seconds left in this prompt. There's probably no need to end on a profound note here, but I do expect that these experiences will be ones that I will remember late into my career. Perhaps codifying them into memory by writing about them will help that become reality. That is, after all, how I attempt to learn everything.
