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Friend or Foe?

A patient with a past medical history of hypertension and IV drug use (IVDU) presents to the ED. He reports a one month history of neck pain. He denies any trauma. He also reports having upper extremity weakness for two weeks. He denies any previous episodes like this. He denies any fevers or chills. He reports an IV drug history for a number of years and reports that his last heroin injection was two days ago. He denies any headaches, blurry vision, seizures, any numbness, and tingling in all four extremities. He was worked up for his neck pain, and MRI showed abscess of cervical vertebrae C5-C6. He was transferred to another medical center for neurosurgical management of the abscess.

Neurosurgery performed debridement and decompression successfully. Jackson-Pratt drain was placed and removed three days later. Patient was initially started on started vancomycin, cefepime, flagyl for broad spectrum coverage three days prior to surgery. Flagyl was stopped the next day as per Infectious Diseases (ID) recommendations. Blood cultures showed Gram positive cocci in clusters, so antibiotics were appropriate at this time. Anaerobic and tissue cultures were obtained intraoperatively and showed no growth. As per ID, switched antibiotics to IV nafcillin every four hours for six weeks, blood cultures: positive for Staphylococcus aureus, Staphylococcus epidermidis and Staphylococcus capitis: methicillin sensitive. Peripherally inserted central catheter (PICC) was placed.

Patient was stable to be discharged home from standpoint of primary team as well as neurosurgery team. Patient’s ex-wife filed grievance to stay in hospital until today, an additional three days after his planned date of discharge. Patient stated that he wants to go to sub-acute rehab. Physical Therapy (PT) was okay with patient being discharged to sub-acute rehab given he didn’t have sufficient help at home for his fall risk. Neurosurgery had cleared patient for discharge as well. Patient is to follow up in ID clinic as well as with neurosurgery.  Counseled patient to seek drug rehab or NA.  Patient is hepatitis C antibody positive, no hepatitis C virus RNA was detected.  2D echocardiogram results were negative, normal valve functioning.  Solace for constipation.

This was the clinical course of a patient that I had followed while rotating on the Internal Medicine service. This seems like a pretty open and shut case of a patient with a chronic epidural abscess secondary to IVDU impinging on the spinal cord at levels C5-C6, which validated the patient`s chief complaint of chronic neck pain with sub acute bilateral upper extremity weakness. The patient was successfully treated with neurosurgery removing the abscess, as well as antibiotics and PICC line placement for rehab and home care.  PT had worked with the patient several days before planned discharge date and he was able to walk with a walker, he was making appropriate progress for sub-acute rehab placement, and he received adequate pain control (he was on morphine 2 mg and evidence of adequate control was exhibited by the patient sleeping and seen laying comfortably on daily rounds and by all nurses at all times during the day). I even took steps to sit with the patient for about 15 minutes while on call and just watch Boyz in the Hood while talking about life and sports.  I knew he was living alone, was divorced in the past few years, and was feeling he wanted someone to talk to. We had a great relationship, and every day the patient stated that he still felt weak and was in pain. I reassured the patient that his recovery from surgery will take time and that we had noticed massive improvement in his symptoms objectively from a neurosurgical, PT, and internal medicine standpoint and the current medication regimen will further aid in his recovery.  His pain was under control (he was started and sent home on Norco, 5 mg) and he would be able to be sent to sub-acute rehabilitation for his subjective problems with walking and activities of daily living.

I do not remember this patient because of the previously described information, I remember him for the in-hospital alcohol use, the petition filed by his ex-wife for premature discharge from the hospital and him needing to stay for three more days, for not going to sub acute rehab (a task that took three days to perform due to no placement on the weekends and patient’s current drug use), but above of all none of this information being provided to me by the patient himself and how my entire team was blindsided. While we were trying to care for the patient (constantly changing his pain management regimen from Dilaudid, Morphine, Norco and adjusting these doses, finding a subacute rehab facility and getting a hospital bed for the patient’s home due to his immobility) he was disrespecting our efforts by sneaking in and drinking alcohol the evening of his planned discharge. The patient’s ex-wife had visited while we were on rounds that day, during which she had no questions for us or the nurses, but then the following day she filed a grievance with the State of Michigan stating that her ex-husband was not ready to be discharged and needed to stay for a few more days. We were not informed about this incident by the patient the next day on rounds but rather learned from his nurse afterwards.  It came as a complete shock and our hands were tied because we couldn’t discharge him or transfer him back to his original hospital system because of the grievance. I visited the patient after hearing the news, and he refused to acknowledge the overnight events until I stated that I knew about them, and then he apologized for his actions. No change in care occurred over the weekend and on Monday we found out from the social worker that if we had a sub-acute facility to send him to then we could discharge the patient. The patient agreed with this treatment plan and was discharged the same day.  Upon arrival at the subacute rehab facility, however, he decided to go home without any other medical equipment.

The tone of this essay has components of anger and resentment (which were feelings I had at the time) but these aren’t my feelings presently towards this patient nor toward future patients that I will encounter who have similar demeanor.  I have learned that there are patients out there like this, and it shows a life lesson that one’s best laid plans sometimes do go awry. One must not let it get to them, but instead to just realize that this could be a possible outcome in some cases without changing one’s approach to handling the situation. We as medical professionals must not let countertransference hinder our treatment of the patient population.

Donald Brown Donald Brown (1 Posts)

Contributing Writer Emeritus

Wayne State University School of Medicine

Donald Brown has a bachelor's in biology and pre-medicine from Xavier University of Louisiana and is currently a Class of 2013 medical student at Wayne State University School of Medicine. He is on the executive board for the Aesculapian Honor Society which recognizes students who are greatly involved in community service and is an active member in the Gold Humanism Honor Society. He plans to pursue a career in psychiatry, and in his free time he enjoys watching and playing trivia and board games, hanging out with friends, and playing basketball and football.