Inpatient neurology at UAB is a busy service, accepting a variety of calls every day from the ED, inpatient consults, and transfer patients throughout the state. On a particularly hectic Wednesday afternoon during my second week of rotation, our team received a page from the psychiatric ward because one of their patients, Mr. S, was being transferred to our floor after a possible seizure. The residents were busy checking out patients to the night team, so I was sent to see the patient first. I didn’t have much information from recent notes except that he had advanced Alzheimer’s disease with severe dementia. I anticipated that it would be a quick assessment.
When I arrived, the door was propped wide open so that the staff could monitor all activities in the room from afar. Mr. S required one-on-one supervision because he was known to be combative with hospital personnel. The nurse assigned to his room sat uncomfortably in a corner sofa, clearly thinking that she drew the short end of the straw that day. The patient was sedated with restraints on his hands and feet for safety precautions. Having a conversation with him was impossible because he refused to open his eyes and was mumbling incoherent profanities. The nurse fidgeted more in her seat as I tried to examine him to the best of my abilities. Knowing that patients with advanced dementia often lose their grasp on reality and act out in their frustration, I moved quickly, not knowing exactly how my patient would react to someone examining him. I reported my findings to the residents after I was done and we agreed to obtain some labs to determine an etiology for his seizure. Then, we would discharge him back to the psych ward as soon as possible since there was not much more we can do for him on our service.
The next day, we received a call from the nurse’s station saying that the sister of Mr. S had arrived, hoping to talk to someone about what had transpired in the last 24 hours. I offered to speak with her to get more history about the patient. The door was still wide open but this time, Mr. S was less sedated, though the restraints were still on his hands and feet. Occasionally he would track who was coming into the room with his eyes, but for the most part, he was in his own world. His sister said she wasn’t aware that her brother was transferred until that morning. She asked what could have triggered the seizure, and I told her that given his dementia, it was hard to get a clear history from the patient himself so we ordered a full infectious workup to determine a source.
The sister paused to take in everything I said. She looked pensive for a bit before finally speaking. She explained that her brother started experiencing memory difficulties seven years ago. Since their father also had Alzheimer’s, he quickly went to see a neurologist who confirmed their suspicions. At the time, he was an avid biker, and even after his diagnosis, he continued to exercise every day. In the past few years, as his dementia progressed, he was no longer able to ride a bike and resorted to walking. Even at a nursing facility, he would walk up to five miles a day until one day, he wandered away from the premises and his behavior became more erratic and combative. In the last few months, there was no choice but to confine him to his bed because he was so aggressive toward the nursing staff. “He always seems to be calmer when I’m here though,” she said.
This time, it was I who was speechless taking in the extensive history I was finally getting about my patient, who in the last 24 hours was “just another psych transfer.” Up until that point, I was not aware of the gravity of Mr. S’s disease progression and its effects on his relationship with his family. In that moment, I was both humbled by how quickly a chronic degenerative disease can change one’s sense of identity and ashamed that I subconsciously dismissed a patient who I already deemed to be helpless. Gathering my thoughts, I assured Mr. S’s sister that we were doing everything we could. With her help, I was able to complete a full physical exam that was impossible to do previously.
Mr. S did not have any more seizures that night. When I checked on him in the morning, I saw him in a completely different light. Before talking to his sister, I was able to compartmentalize him as another patient who needed to be worked up and discharged. Instead, he became the Alzheimer’s patient who was the enthusiastic biker with a family that was watching him slowly deteriorate from his disease. He was more alert but still not communicative. I took out my stethoscope and spoke to him: “Mr. S, I’m going to examine your heart and stomach.” The nurse who was taking his vitals looked at me with both surprise and pity. “You know he can’t understand you,” she said as she kept typing on the portable computer. I paused, and then replied, “I know,” before continuing the exam. She shook her head and walked out of the room. I can’t really explain why I decided to talk through my exam with Mr. S that morning. I have no doubt that the nurse shook her head at me because I looked very naïve speaking to my patient with the same practiced spiel that every medical student learns through his or her clinical training. In truth, I was hoping that by addressing him the same as I would with any other patient, a little part of his old self would emerge. Perhaps that was very naïve of me.
Before starting my third year of medical school, I was told by many senior students and working physicians that I would soon learn not to be surprised by anything that I see around the hospital. By the time I started my neurology clerkship, I was nine months into my third year and I was indeed burnt out and unperturbed by the variety of patients I saw. It wasn’t that the medicine was uninteresting. I was jaded because I felt that as a lowly medical student, I could do absolutely nothing about how people took care of their own health. For the longest time, I thought that the only way I could impact patients was through direct medical care, which was always managed by residents and attendings. My experience with Mr. S wasn’t a single moment that suddenly changed my perspective on medicine, but it was a reminder of why I wanted to be a doctor in the first place. No matter the specialty, our profession allows us to observe different stages of the human condition in a capacity unparalleled in any other field. Ironically, it took a case where I felt the most useless to make me realize that I can be helpful just by taking the time to care.
I don’t think it’s possible for physicians to constantly adopt a moral high ground. It’s hard not to let our own biases play into the way we treat patients (case in point above). The best we can do is focus on the fundamentals. We take a history to help us diagnose a patient’s chief complaint. While we usually focus on the history of present illness, we also use the history taking as an opportunity to get a better sense of how the patients think and how they want to be helped with their illnesses. Then there are cases like Mr. S where the pieces of history we obtain paint a picture of who that person is or used to be that cannot be otherwise communicated by the patient himself. It reminds us that although they can no longer hold a normal conversation, they are just as human and deserve to be treated the way we want to be treated ourselves. It is idealistic, but it also gives purpose to the many sleep-deprived days to come.
“And I told you to be patient
And I told you to be fine
And I told you to be balanced
And I told you to be kind
And now all your love is wasted
And then who the hell was I?
And I’m breaking at the britches
And at the end of all your lines
Who will love you?
Who will fight?
Who will fall far behind?”
Skinny Love — Bon Iver
Author’s note: The patient’s name was changed to protect identity.
Many of us go into med school with big visions for bettering modern medicine, but as we go through this journey, we realize that there is still a long way to go, and we can’t do it all alone. This column is not meant to be extremely profound or didactic but simply a reflection on the what it means to stay human in midst of society’s expectations and our own expectations.