Lasting Impact: Patient Stories

Our medical trainee writing contest, wherein respondents provide short answers to the question “What patient has had the biggest impact on you thus far?” has proven very popular. We decided to extend to everybody, from trainee to retiree. Our first batch is below. Hopefully this will become an ongoing series, so if you are interested, send your story to Heilig@sfmms.org.

VICTIMS OF INJUSTICE

David E. Smith, MD

In June 1964, right after I graduated from UCSF, I was on duty as an intern in the SFGH emergency department on the final night of the Republican convention here. I was watching an attending physician stitch cuts on the face of a drunk Rockefeller delegate who’d been hit by a drunk Goldwater supporter at the Republican convention. A call came through the hall for all surgeons: There was an incoming car accident victim with legs amputated to mid-thigh.

“Finish up,” my supervisor told me, as he sped out of the room. The last stitching I’d done was to place electrodes in the back of a hibernating hamster, but there was no time for my insecurities. I got to work on my patient. Just like my hamsters the patient did well; it was a great lesson in county hospital emergency medicine. But simple cases like those would never truly prepare me for the heartbreaking losses – especially those cases that piqued my awareness of social injustice.

So, another time, a woman came in feeling “very sick.” She spoke Spanish, and the teenage daughter who accompanied her translated for me as I did the intake, took her vitals, and inserted an IV for fluids. She had shaking chills but no fever, which suggested she was in septic shock. I asked the daughter what had happened. Suspecting that I was seeing the aftermath of a botched abortion, I explained that this could kill her mother. The daughter said her alcoholic father had left the mother raising three children alone. The mother became pregnant and, despite being a devout Catholic, had gone for an illegal abortion. With that information, we rushed her to the operating room for an emergency hysterectomy. It was too late. She died on the table. She lost her life because the law forbade the prompt medical care she needed, and because her family felt they had to delay treatment as her condition worsened. I have been prochoice ever since. And now a teenage girl would be responsible to raise two children without a mother or a father.

I can’t fathom how anyone who has had to care for a woman brutalized in this way could ever be against the right to choose. In my childhood, I witnessed my mother giving dedicated nursing care when she herself was suffering. I saw my father get the care he needed, even though it did not save his life. I wasn’t prepared for this: I watched a woman die because judgmental others stood between her and medicine’s ability to save her life. David E. Smith founded the Haight-Ashbury Free Clinics in 1967, was a co-founder of the specialty of Addiction Medicine and a President of the American Society of Addiction Medicine, has received UCSF’s highest awards for service to medicine and public health, and is a 53-year member of the SFMMS.

CIRCLE OF JOY

Susan Shen, MD, PhD

In the inpatient unit, O. lies motionless in bed, her hair tangled like an abandoned nest. Most days, she offers a fuming “f--- you”! Sometimes, she yells, “Leave me alone!” and wanders the hallway, her eyes like dark orbs in another galaxy. When she sits at the dining table, she mechanically brings her fork to her pale lips. Her grieving mother always brings her food that rots away at the bedside.

I begin to despair. Medication after medication, her soul remains buried in an unmarked grave. Eventually, there are no more medications to try. Only one thing is left: electroconvulsive therapy. A life-saving treatment that requires a litany of paperwork despite the medical urgency. Paperwork I fill out before I go on maternity leave, leaving behind wisps of hope.

When I return to work foggy and sleep-deprived, my mind wanders in and out of baby-land. I come home and robotically bring my breast to my baby’s pink lips. I am desperately trying to take care of a helpless human being.

Over the coming weeks, I slowly emerge from my haze. I learn that O. received electroconvulsive therapy, to great effect. She stopped screaming profanities, she started talking with her peers, and she even started to smile a little. She had already left the hospital.

Today, I watch as my baby giggles and coos. I remember O., whose depression robbed her of all joy. I remember that life begins with joy, and joy can return if we fight for it. Susan Shen, MD, PhD is a psychiatry resident at UCSF.

PATIENT UNKNOWN

Natalie Neale, MD

I was on my neuro ICU elective when I first encountered a patient’s name listed as “unknown” in the EMR. The patient had been “found down” on the street after suspected opioid overdose. In the neurologic ICU, he was essentially brain dead, save an intermittently reactive pupil which we treated as needed with mannitol. Any attempts at saving this man’s life or recovering brain function would be futile. He had no advance directive and no readily available contacts, but after detective work we were able to track down the names and contact information of two of this man’s close friends from his halfway house. We met with the friends and our ethics committee, and based on the collateral information came to the conclusion that this man would not want life-sustaining measures. He passed away with his two friends at bedside. Even though he was not conscious of anything, it still felt important to me that someone was there who knew him and cared about him.

I suppose the reason this patient stuck with me so much is that he made me think about death in ways I never had before. Maybe it sounds obvious, but I think that compassionate care should extend to the last breath of the patient, not just up to the point where the patient is conscious. In the end, I was proud that my team was able to give this patient a “compassionate death,” surrounded by people who cared about him. Natalie Neale, MD is a resident in neurology at UCSF.

MURDERED SLEEP

Michael Schrader, MD

You might have seen this story on the evening news but I didn’t hear it until they called me at 2 am. I like to pretend that things that happen at work don’t bother me, but that isn’t true. Most of the tragedies I just forget. I have taken care of patients for a quarter century at a San Francisco nursing home down the hill from St. Mary’s Cathedral where Ellis Street dead ends.

Annie was an elderly demented woman who had lived there several years. I started taking care of Annie three years before because her daughter was unhappy with the previous physician. There was a minor issue of tweaking thyroid replacement initially but then everything was stable for years.

She was confused but pleasantly conversant. She was cute. Whenever I would go into her room to round she would look at me coquettishly and say, “You’re so handsome.” She always said it. And it always made me laugh.

One evening Annie’s daughter came to visit, paid the monthly bill and went to Annie’s room where she murdered her with a handgun and then killed herself. The staff were used to gunshots in the neighborhood and didn’t check the room for a couple of hours.

The police came. The TV news came. They cleaned the room. They remembered to call me at 2 am.

I lay in bed that night for a couple hours after that thinking about poor Annie and that line from MacBeth about murdered sleep. No one ever knew why her daughter did it.

I talked to James the night nurse about this a couple months ago. James brought it up. He was on duty that night and found the bodies. It was he who had to clean the room. They gave him two weeks paid leave for his trouble.

I was in the room the other day. It’s a different color from the other rooms because they had to repaint. You might have forgotten this story, but James and I remember. Internist Michael Schrader, MD, PhD, is president-elect of the SFMMS.

AN EMERGING SOCIOECONOMIC CURIOSITY

Anthony M DiGiorgio, DO, MHA

I was a junior resident when Mr. X arrived at our ED. We operated on his traumatic brain injury. He survived that and a lengthy ICU stay. Four years later, he died in our hospital. It was the same admission.

There was nothing unique about the medical or surgical care of Mr. X. He was just another polytrauma patient with a subdural hematoma. Functionally, his recovery was slow but substantial, typical for TBI.

The remarkable part of Mr. X’s story is that, for four years, he remained in the hospital. While he recovered significantly, he never regained functional independence. He couldn’t be discharged home. No post-acute care facility would take him. His family did not have the means to care for him.

My experience with Mr. X is just one of many which contributed to my interest in health care economics. I realized that, while medical school and residency taught me how to treat Mr. X’s disease, that was only part of the story. Unfortunately, there are more than a few patients like Mr. X, patients who are denied the care they need because of economics. In trying to understand these patients, I found myself learning about insurance, economics, policy making and administration. I realized how little the economists understand medicine and how little doctors, like myself, understand economics. To fully treat Mr. X, and the thousands like him, I needed to expand my focus to administration and advocacy. Anthony M. DiGiorgio, DO, MHA is Assistant Professor, Department of Neurological Surgery, at UCSF and Zuckerberg San Francisco General Hospital.