Thursday, February 25, 2010

Last Night??!!?

I saw a patient today in clinic at the Zoo. He was diagnosed with HIV in December. Actually, he meets criteria for AIDS, because his immune system is so shot. He also had a terrible brain infection with Toxoplasma gondii. He came in, at that time, very confused and unable to care for himself. His wife brought him in. She, fortunately, says she tested least so far.

I see him today, 2 months after being discharged from the hospital. He left with 3 medications to treat his meningitis. He told me that he stopped taking his medications a week or so ago, because he felt that they were causing burning when he urinated. I think my jaw hit the floor. He has an active parasitic infection in his brain, and he stopped his medications on his own because of some pain when he pees. He claims the burning has stopped now that he's off the medications. I'm not challenging that he got the symptoms - people get weird side effects from medications. I'm questioning his judgement and understanding of his illness in stopping his medications without consulting a doctor.

I looked at my translator and asked about 3 different ways if he was really not taking his medications. His wife agreed that he had stopped taking his meds. She didn't seem to think this was unusual at all. Their 3 year old boy was playing with the paper on the examination table, and all I could think was, "This kid isn't going to know his father." The man has a limited lifespan even in the best case scenario, and not taking his medications does not exactly put him in the "best case" category.

I presented him to Dr. D, the attending, who is very hands-on when it comes to couples with HIV. She wanted to come talk to them herself.

She asked if the wife had been tested - she claimed yes, and it was negative. The wife then claimed that the nurse hadn't set her up for a repeat test. Repeat testing is standard procedure - in discordant couples the negative partner should be tested every 6 months. So, we began to question if she really got tested in the first place. Dr. D asked them when was the last time they had sex. The wife looks at the husband, who says "Ayer." I think he's speaking English, and I ask, "A year?" The translator looks at me and says, "Last night" (literally, "Yesterday"). Dr. D looks at them and say, "Last night?!!?!" She then went on a rampage about how he has a sky high viral load, is amazingly infectious, and does she want her child to be an orphan. She said, "I don't want you having any relations until he is on HIV medications." They agreed, but I am not convinced they are going to follow this advice.

We explained backwards and forwards how HIV works, how serious his brain infection was, etc. They kept saying they understood, but they didn't look scared enough to have understood. Even the translator was worried for the wife.

They are supposed to come back next week, hopefully after him returning to taking his meds, hopefully with her getting an HIV test again, and hopefully with them in the right mind to take care of themselves. We don't need another child watching his parents die of AIDS.

Saturday, February 20, 2010


I am moonlighting this weekend. It's for an Infectious Diseases group, so I like it. I get to see some interesting cases, learn from those great MDs how they are managing the cases, and I get to make some extra cash. The only downside is I have no day off for weeks and weeks. Oh, well, there are pluses and minuses to everything.

I had a patient today who was really interesting. I think I've said this before, but a patient's wife once told me, "You never want to be an 'interesting case' - it doesn't usually bode well for the patient!" She's right. "Interesting" to doctors usually means rare, bizarre, and usually portends a bad outcome.

This super cute, elderly patient had a bone infection in his ankle and foot, because he's bed bound after a massive stroke. He got a pressure ulcer on his ankle with an infection that eventually settled in to the bone. That, in and of itself, is not interesting at all. That's run-of-the-mill infectious diseases. Dime a dozen stuff. His stroke, however, produced a fascinating symptom. I'm pretty sure "fascinating" can be added to "interesting" in the list of things you never want to be called by a doctor.

The patient is aphasic. Wikipedia has a great chart that describes a bunch of different language disorders often resulting from stroke or brain injury. This patient has Wernicke's aphasia. He probably doesn't understand me much, but I can't tell because I can't understand him at all. He has no trouble enunciating. His words are just a bunch of garbage for the most part. Some are real words. Some are made up. Most just don't go together at all.

I asked him how he was doing. He said, "Well, the angels all go in a row, and then baddle and baddle, and then it's done." He then looked at me and asked, "How diddy come splot and biggin to know?" I had no answer, so I just said, "I'm not sure..." It was terrible, because I didn't know if he comprehended that he made no sense and that I had no idea what he said. He seemed happy enough, "pleasantly demented" as we usually say. But, in this case, he's not demented, he just has a problem with the language center of his brain.

I'm assuming he didn't realize that he was not making any sense, or he would've gotten frustrated with my lack of a response. So, I guess that's a silver lining in his case. I told him his antibiotics were working, and that he'd be out of the hospital soon.

He said, "There you go."

Wednesday, February 10, 2010

Guru in the Clinic

Last week, I returned to Clinic at the Zoo. [If you've forgotten, I've termed the county hospital the "Zoo" - a) because it rhymes with the real name and b) because it really is a free for all up there.] It was, as usual, extremely busy. I never feel like I can give great care in that environment. There are way too many patients smashed into a 4-hour morning. Even when the 4-hour morning turns into a 5-hour morning (as it does 99% of the time), it's still not enough time. I don't get to look through labs as closely, I don't get to ask enough questions and I don't get to really know the patients.

Last week, I had an older man who had moved here from India about 10ish years ago. He was quite funny and nice. He had a nonhealing foot ulcer, but it was gradually getting better. He was refusing amputation, which would've cured the infection and probably (eventually) given him greater mobility. But, he was rather attached the foot, so I didn't push it.

He started giving me little words of advice, like a talking fortune cookie. I spent quite a bit of time with him (relatively speaking), partly because I liked his sound-bites of wisdom and partly because he seemed like he enjoyed an audience. He said, "If you're driving a train, you cannot stop and remove all of the little pebbles on the track. You will never get where you're going. Those pebbles are like life's problems - you just have to keep going and push them out of the way." He said a few other snappy things which were very inspirational. I wish I could remember them all. I told him that his family and friends are very lucky to have him around.

He looked a little sad, and he said, "You know how a lamp gives off light - lots of light! - everywhere except underneath the lamp. That is like me with my family. They do not see my light, they only see me as a old man." I wished I could've spent more time with him. I told him I'd see him in 6 weeks, and I thanked him for being a light to our clinic.

Wednesday, February 3, 2010

Just Takes One

I had a patient today with diabetes and a nonhealing foot ulcer. He has already has a below the knee amputation on the left. He's probably going to need another one on the right, due to the ulcer.

My attending starting to talk to him on the importance of good diabetic control to avoid even further complications. The patient cut him off and said, "Doc, I mean no disrespect, but I don't want to hear it." He said that no one ever listens to him, people just sit and lecture him about his illness, and he doesn't want any more of it. The attending is a very, very caring man and really tried to talk to the patient on a more personal level. The patient just shut down.

Once the attending left, the patient told the med student and me his reason for being so angry. It seems he had a bad experience once with a nurse. She told him that he needed X units of insulin. He said that X units had cause him to have an episode of hypoglycemia - he got shaky and passed out. Hypoglycemic episodes can be scary as well as life threatening.

He told her what had happened the last time he took X units. He asked, "So, how many units do you think I should take now?" She looked at him and said, "X." No difference, no acknowledgement of his past symptoms, no regard for his fear of another bad event.

All it took was one bad encounter, and this patient has closed himself off from having an honest conversation about his diabetes. It's sad, but it happens all the time. I think we healthcare providers forget that just one encounter with us can make a lifelong impression -- for bad and for good. We need to listen to our patients, let them know that we really hear what they are saying, and approach things as a team. The only way to be effective providers in patients with chronic diseases is if we're both on the same side.

Monday, February 1, 2010

"I don't think you have cancer..."

So, this past month has been pretty light. I had vacation for 2 weeks, then I had clinic only 1 day a week for the rest of January. Those last 2 weeks were supposed to be for research. I took "research" to mean sleeping in, working on an art project, and reading the occasional medical article. I'm pretty sure that's what it means. [Some people may be dismayed by this idea that their doctor is off somewhere wasting time rather than reading every new article that comes out. I prefer to think of it as making myself well-rounded.]

I covered this last weekend at the hospital. Thirteen patients to see each day, so not bad. One I saw on Sunday is a middle aged man with an intestinal disorder that requires he takes steroids. This makes him a little immunocompromised and at risk for weird infections. He came in with abdominal pain, which isn't unusual for him given his condition. What was unusual is that the abdominal CT scan picked up a weird finding in his lower lungs. A scan dedicated to the lungs confirmed a weird nodular pattern with a focal problem in one of the upper lobes. Now he's got to get a procedure done to figure out what the heck is going on in his lungs. Could be an infection (hence the reason I saw him) or cancer or some other inflammatory process.

He looked sad, so I asked if he was doing ok. After chatting for awhile, he said, "Do you think it's cancer?" To be honest, I have no idea. I suppose I could've said that: 'Well, sir, I'm not sure that's why we need the biopsy.' But, he knows that. So, instead I said (with as much confidence as I could muster), "Well, maybe I'm biased since I do infections for a career, but this pattern is more suspicious for an infectious process, I think." I'd like to say he breathed a sigh of relief, and I renewed his hope in the world. What really happened is he looked at me skeptically and didn't say a word. So, I said, "We should know for sure by the middle of the week, when we have all the results back. Either way, we're going to do our best to get you through this." Again, he didn't look all that convinced; I said good bye and put my note in the chart.

Sometimes you just can't make someone feel better. Sometimes they are too scared, too nervous, too cynical to think they might catch a break. He's been sick his whole life with an incurable intestinal disease. Why should things start looking up now? I encouraged him to have a positive outlook, and we'd see how things went.

Maybe some people are just hardwired to be "glass-half-empty" and nothing you can do is going to convince them that it's also half-full.