Chapters 27 and 28: "Internal Medicine," and "Radiation Round Two"

 

Chapter 27: internal medicine

Starting my inpatient internal medicine rotation reminded me of why I went into medicine. I loved every minute of it. I had the fortune to work with an incredible team of residents with passionate and knowledgeable attending physicians. My senior resident (the “team boss”) was phenomenal at creating a fantastic atmosphere. She was deliberate about giving me space to think about and propose management for all of the patients I was following, as well as helping me to be the main point person to the patient even as a medical student. If the other interns started discussing my patient before I had proposed a plan, she would stop them. It was incredibly kind and ensured that I could maximize learning and practice of becoming a real doctor. We’ll call her Doctor A. I’m incredibly grateful for Doctor A, and should I ever become a senior resident, I will do my best to emulate Doctor A’s phenomenal team-leading example.

              Our team is long today, which means I’ll stay overnight for my first shift. I suddenly realize that I’m unprepared—I brought neither contact solution, glasses, or a toothbrush. Later that day I get some supplies from the nursing station. A toothbrush and some saline and two containers for the contacts. Before long, I get my first patient to admit. I grab my stuff and go down to the ED to see them. Doctor A tells me to call her if the patient looks super sick or unstable, or if I think I’ll need help.

              I go to see him. He looks profoundly sick. His skin is a dark yellow, with yellow eyes and several dark bruises across his extremities. His belly is full and taught. He looks uncomfortable. I look at his vitals, which are normal, that’s a relief. The ED physician tells me that he’s here for abdominal pain. The patient tells me that he’s been here for this before. He has cirrhosis—his liver doesn’t work anymore. He got this from drinking alcohol. The other night he went out drinking, and then he tells me that his belly swelled up and his legs began to swell and it was all very painful, so he came in. He’s never had a surgery, he doesn’t have allergies. He tells me that he hasn’t used any other drugs and he doesn’t smoke. I go through the review of systems, but no other symptoms seem to concern him right now. On his exam he has a finding called “asterixis,” which is a repetitive relaxation of the muscles when you attempt to hold them in some form of flexion. We usually ask people to hold out their hands like their trying to stop a bus, and a positive finding is when the hands repetitively flap downward. This means that he has some hepatic encephalitis, meaning that his liver is so unhealthy that he cannot filter out toxins from his blood, and these toxins are interrupting nervous impulses. It can be a fatal decomposition. In someone with acute liver failure (not chronic like this man), encephalopathy is one of the criterion for transplant. I thank the man for his time, then tell him about the plan to bring him up into the hospital floor, where the team I am on will care for him. I let him know that he will meet several other doctors up there who will care for him.

              I go back up to the team room. I tell Doctor A about the patient, I tell her he looks sick but not unstable. Then I explain that I believe he has decompensated cirrhosis and hepatic encephalopathy, and go through my evaluation and treatment plan—including labs, special medicines to help him poop out some of the toxins more effectively, as well as methods to remove some of the excess fluid. Doctor A tells me that based on the patient’s chart she agrees, and that she’s going to go quickly see him. Meanwhile the patient’s labs come back. I use them to calculate something called a MELD, which is a statistical tool to predict a 3 month mortality for patients. I calculate his and it tells me that his estimated 3 month mortality is 25%. I’m shocked, I wish that I did not know this information. I wondered what was the point? This was an individual, why was I using a population-derived average in order to try and predict his course? Would it help with treatment? But in the end it did help me realize that he would die soon, no matter what happened in this hospitalization. Doctor A came back, we talked briefly about the patient. I shared the MELD score and suggested that we get palliative care on board. She agreed. I thanked her for her help. She told me that our attending physician would be by later that afternoon to staff, which is where I told them about the patient and my plan, kind of like the college mornings in the first two years of medical school. She asked if I could call his family after we staffed. I thanked her for the opportunity and agreed. I sat down at my computer and wrote my admission note—usually a formality that feels more like busy work as an intern or resident—which helped me organize the interview and my thoughts and plan. By the time I finished writing, the attending physician came by. As a team we went over to the patient’s new room and huddled outside, where I presented the patient and my plan. The attending told me my presentation was good and that he agreed with my plan. I felt validated. Then he peppered me with questions regarding the pathophysiology of cirrhosis and decompensated cirrhosis. I was able to answer all of his questions. He told me good work and asked me what I wanted to do, and I told him initially family medicine but that now I was considering internal medicine. He told me that it would be a good fit. A career path was opening. Then we went to see the patient together and I explained the situation and plan to him as best I could in non-medical language. It seemed like he understood. Then I asked if it would be alright for me to talk to his family. He said yes and thanked me. I got his wife’s number from him and then we left the room.

              When we got back I called palliative care to consult them for my patient. They asked if he had seen palliative care before. I didn’t know, but I told them he was expecting them. They agreed to see him and told me they would be by tomorrow and then call back with recommendations. I thanked them. Next I picked up the phone and called my patient’s wife. Yes, she was aware that he was in the hospital. She tells me that this happens all the time and that she’s not surprised. She asks if he’s going to die. I answer honestly and tell her that I don’t know, but that he’s stable at the moment and that we’re doing our best to keep him from decompensating. She thanks me. I tell her our plan, she is in agreement. She asks if there is anything she can do to keep him out of the hospital. I talk about medicines we could give him when he leaves, and that he needs to stop drinking. She understands. I tell her that we’re going to have palliative care see him because he is so sick and has been in the hospital frequently. I explain that they are doctors that specialize in comfort and end-of-life, but that this doesn’t necessarily mean he is at end-of-life right now. She tells me that she thinks that is a good idea. She asks if she can be around for that discussion. I tell her yes, and that the palliative care team plans to be by the following morning. She thanks me and tells me that she will be there. I thank her and tell her that I’m glad to hear that he has this support in his life. Talking with the family feels incredibly meaningful and reasserts my commitment to medicine.

              Night comes and the other medicine teams sign out patients to my team. Doctor A tells me that I should just go to the medical student call room and get some sleep. She doesn’t want me to stay up and deal with pages because I can’t put in orders on my own anyway, so I would need to get her or one of the interns to help if I got a page anyway. She tells me she’ll call me if there are any new admissions to do overnight. I thank her, grab my stuff, she shows me the call room. I enter, there’s a bunk bed with two flimsy looking twin mattresses with thin sheets and a pillow that appears to be packed with sawdust or Styrofoam. I set my stuff down, go to the sink to get ready for bed, take off my shoes and climb in. I ensure that my alarm is set to 530 AM so that I’m up early enough to look up patients before rounds—where we go and talk about each patient and the plan for the day—I had been assigned two additional patients for the next day. It had been a good day. Despite anxiety about being called for an admission, I sleep incredibly well.

              I wake the next morning, throw on my shoes and a new pair of scrubs from the closet, get ready for the morning, grab my stuff and go down to the cafeteria. I grab the largest cup of coffee that I can, then head back up to the team room. Everyone is there except the attending, all with large coffees. I ask how the night went. They say well, there were no admissions and they didn’t get many pages. I was glad to hear that. Doctor A tells us that the attending will be there at 10 in the morning to do rounds. I get a sheet of blank paper from the printer and my pen, then log onto the computer and start looking at my patients for the morning. Not good, the decompensated cirrhosis patient I admitted looks worse. His blood pressures are a tad lower than before, and his labs have worsened. I’m worried, it feels like we’re already maximizing medical management and I don’t know how to escalate his care. After looking at all my patients’ charts, I do what’s called pre-rounding, where I briefly interview and do a physical exam on each one before our actual rounds, so I can present it and incorporate it into my plan. My patient looks more yellow than before, his belly looks larger as well. I ask him how he feels and he tells me worse than the previous day. I feel like I’ve failed him. I tell him we’ll do something different today and try to get him feeling better. On rounds I suggest fluid restriction as well as a paracentesis—where we physically put a needle in his abdomen and remove the fluid pooled around his organs. The team agrees with my plan. His wife is in the room. I introduce myself. She asks when the palliative care team will be there. I tell her that I don’t know, but that I suspect it will be soon. We move on to the other patients. The interns present. I’m impressed by their concision and confidence and ability to think on the fly. I wonder if by the time I am an intern I will be similarly skilled. I hope so. Later I tell them that I’m impressed by their presentations and ask if they can give me feedback whenever they think of something. They agree and I thank them.

              Rounds continue. My phone rings. It’s the palliative care team. They tell me that they just saw the patient and his wife. They tell me that they decided to be DNR and DNI, meaning that the patient would not want chest compressions if his heart stopped, and would not want intubation if he could no longer breathe on his own. They also tell me that his biggest concern right now is comfort, and agree with our plan for a paracentesis to get fluid and pressure off, then suggest several medications for pain and comfort that would be safe with liver disease. They tell me that they will put in the orders for these things, and I thank them for their help. Lastly, they tell me that if he begins to actively die, that his biggest wish is for his dog to be with him as it happens. I thank them for that information and tell them I’ll talk to the nursing staff to see what we can do. Doctor A asks about the conversation. She’s touched by the dog part, then says that she doubts they’ll be able to do it, but that we’ll try our best.

              Rounds finish. We finish our notes. We write sign-out to give to the team on call, then sign out. It’s time to go home and sleep. I take the bus back. As I enter the condo complex an older woman is coming down the stairs. She asks me who I am, and tells me she’s never seen me before. I tell her that I’m a cousin staying. She doesn’t believe me, stating that he always has different cousins staying and that I look nothing like him (the host). I can’t blame her, she’s correct. I tell her I’m tired and need to get some sleep. As I go upstairs she yells “you shouldn’t be here!” It felt vindictive. What was I supposed to do about it? She was lashing out at the wrong person and I needed a place to stay. I get into the condominium and go right to sleep. I sleep about 4 hours. When I wake up I make a quick cup of coffee. I walk across the street to Safeway and buy things to make meals. When I get back I make a quick meal, then take out my laptop and begin to study. I’m enjoying internal medicine and I’m extremely excited to learn more so that I can better help patients.

              The next morning I wake up and get coffee as usual, then make my way to the hospital. The team is there when I arrive. I look up my patients. My cirrhotic patient received his paracentesis. They took off more than 3 liters of fluid. The nursing notes state that he is feeling better. But looking at his labs and vitals, it looks as though he’s still decompensating. I go to see him. This morning he is more confused, but he states he is happier because his belly doesn’t hurt anymore. He asks when he can get out of the hospital. I tell him not yet, that we need to get some labs improved and help his confusion first, and that we need a better plan to keep the fluid off. His wife is in the room still. She thinks this is a good plan. I do a physical exam. His Yellowing is worse and his asterixis is much more pronounced. I’m worried. I think that he’s actively dying. Back in the room I recalculate a MELD, his 3 month mortality is now greater than 50%. Doctor A has seen him this morning too and agrees that he will likely die soon. We needed to get his dog to him now. I call the charge nurse on his floor and explain the situation and ask if there’s any way that we can get his dog into his room. She tells me that they shouldn’t, but that she’ll convince the nursing and other staff to turn a blind eye if the patient’s wife brings the dog. I thank her. After reading up on my other patients, I go back to my cirrhotic patient’s room. I explain that as a team we are worried that he is dying. His liver is bad and not getting any better, and his kidneys are beginning to fail as well. The wife understands. I tell her that we talked to the charge nurse and that she can go bring the dog whenever she would like. She asks if she can stay as well. I tell her yes. She asks if we can make sure he’s comfortable if he starts to die. I tell her yes and that the palliative care team will help us to ensure that. I thank her for being here and helping him. She tells me that she is going to leave to pick up the dog, and asks if we can round slightly later so that she can be back in time for it. I go back to the team room and explain everything to Doctor A. She states that we can go to him last on rounds.

              Our attending arrives. Before rounds he wants to share with us a book he wrote or helped write. It’s a book on sexually transmitted infections, with several pictures. As he opens it for us to show us the pictures, he reiterates repeatedly that the hands holding or displaying the various genetalia are not his, while sharing interesting facts about each disease. He’s very knowledgeable and it is quite interesting, but we cannot stop laughing every time he states “the hands are not mine.” It’s a much-needed bit of comic relief for what has otherwise been a heavy morning. We start rounds. Eventually we get to my patient. I present. We enter the room. A corgi is nestled on the patient’s left side and jumps down to greet us as soon as we enter. We each give it a quick pet. It’s a super cute dog, then it jumps back up to be next to its owner. The patient looks the calmest I have ever seen him, and the wife looks relieved. She tells us that she is so pleased that he could have his dog with him, and that the dog and him had been best friends for years, and that she thought he loved that dog more than anything in the world. I was honored to know that we were able to respect and manifest this man’s dying wish.

              We finished rounds, then went back to the team room to get some work done. Later that afternoon I get a call from the nurse that my patient’s blood pressures are dropping and that she thinks he’s dying. She asks what I want to do. I briefly talk with Doctor A first, then we decide to give him the as-needed comfort medicines suggested by palliative care to make passing more comfortable. The nurse says she will do that, and that she’ll call if anything changes. My patient dies later that afternoon. After I hear about his passing I go to his room. There is an awful fecal stench emanating from the room. I enter, the dog is still at his side and his wife is still in a chair nearby. The wife tells me, “I think he died.” I say, that’s what I heard. I do a brief exam and confirm the death with her. The dog will not leave his side. She thanks me. I ask her if it were peaceful. She tells me that his death looked peaceful, and that this is how he would have wanted to go in general. I thank her for sharing this with me, and for her time and for being here with him in his final moments. I ask her if she needs anything. She tells me no, and that she would like to wait until the evening to take the dog and leave. I tell her that that is OK. I look out the window. It’s raining now. This was my first patient death. I felt strangely devastated, and somehow like I had failed. Maybe an equally important part of medicine was bridging to death, but we were never taught to value or promote that, and I thought about how death seemed to be a major hole in the medical education complex. After leaving the room I call Doctor A, explain that I think he is dead, and tell her the wife’s wishes. She thanks me and states that she’ll start on the paperwork. There is a copious amount of death paperwork, which I cannot fill out because I am not yet a physician. I thank her, then go back up to the room.

              When I get back she asks me how I’m feeling about the whole thing, and asks if I’ve seen a patient die before. I tell her that this is my first time, and that I feel fairly dejected and defeated. She gives me a hug and tells me that that is normal. She tells me that our job is not to stop death, but to ease suffering, even if death comes to the patient. She explains that we did everything right for the patient, that we did nothing wrong, and that I shouldn’t be ashamed. I thank her for her words—they’re incredibly reassuring. Sometimes all you need is someone who’s done the journey before to tell you “I’ve been there, and it’s OK, and you’ll be OK.” She asks if I would like to take a moment. I say yes and thank her.

              I leave the room and go up to one of the upper floors where I know there’s an outdoor balcony. I walk out onto and put my hands on the rails. The rain wets my hair and face. It’s cathartic as it washes over me. I don’t know what to do, or how to reflect. I look out into the distance and begin to recite an old poem that I had memorized: “Oh Captain my Captain,” by Walt Whitman. I end up reciting the poem to myself several times. As a poem about loss, the prose becomes a rhythmic comfort. After several minutes my spirit feels somewhat healed. I begin to feel thankful that I was privileged enough to be there for another person’s death and help them on that journey. My whole reason for doing medicine was to better understand death, and now that was starting to happen. I felt better, and thought to myself that I would probably do this again if I had another patient die. Then I walked back down to the team room, stopping for a paper towel to wipe my hair and face along the way. When I returned the team asked how I was feeling, I told them “much better,” and thanked them for giving me time. Then I told them I was ready to continue working and could take the next admission. They told me that that was OK. I was sad to know that I would be switching teams in two weeks. I had come to love and care for the team I worked with, and they were certainly an incredibly positive force in my medical education.

              …

              And so the rotation continued. Eventually I switched teams. The next team was fantastic, although nothing could compare to the first. The clinical portion of the rotation ended. Doctor S, the director, told me that I had done a great job based on evaluations that were submitted, and that I would do well in internal medicine. I thanked him and asked him for a letter of recommendation for residency, which he agreed to, and I thanked him. Next would be the outpatient portion of the rotation, which I was to complete in the rural town of Moses Lake, WA.

…

              Suffice to say, the outpatient rotation was fantastic. It was lonely because I lived in a house alone. The attending that I worked with was attentive and knowledgeable and kind, I'll call him Dr. G. He would give me a list of approximately 4 patients each morning for which I had primary responsibility. It was the most independence and responsibility I had had in medicine yet, and I began to felt like I was on the road to becoming a real doctor. I’m incredibly grateful for the help of that outpatient internal medicine doc,  and while I was still convinced on inpatient medicine, I finally felt as though I would be ready for residency when it came. At the end of the rotation he offered to write me a letter of recommendation as well, I thanked him and told him that that would be incredible. And then it was time to go back to the city to take the large end-of-rotation written exam. I will say that I would not miss Moses Lake. While it was a small town without too much to do, every morning a putrid smell would fill the air—I was told from decaying frozen potatoes—that made it difficult just to be outside. I take the exam, it goes well. Several weeks later I get my evaluation (grade), and learn that I got Honors, which is the highest grade achievable. I’m ecstatic. I call Elizabeth and she congratulates me. Since I wanted to do internal medicine now, it was incredibly important that I got a good evaluation in the rotation. I begin to feel more certain in my future, and I’m no longer worried about upcoming rotations.

Chapter28: Radiation round two

I started my second round of radiation therapy in early August after an initial infusion of pembrolizumab. This was the immunotherapy we decided upon, which basically removed the limiter on my adaptive immune system so that my immune system could recognize and attack the cancer cells. The idea was that with the radiation therapy, the blood-brain barrier that usually prevents other cells from getting into the brain’s environment would get somewhat degraded and it would allow more immune cells in to attack the cancer cells. I also received an infusion of a medicine called Avastin, which was designed to decrease capillary leakage and vascular growth. The idea was to decrease any swelling and to try and prevent brain edema in the setting of inflammatory radiation and with the attack of immune cells on cancer. It was a safety medicine. I was grateful to receive it because I believed that it would help keep me stable and keep me out of the hospital. The infusions were uneventful. I did not feel any different afterwards, although I did develop a horse voice, which was a common side effect with Avastin.

              The next day, radiation therapy began. That morning I drove to the hospital. I was strangely excited. I was incredibly grateful to be finally starting radiation. It was a therapy that I knew killed cancer cells. I was comforted to know that the residual cancer in my brain was being attacked, especially in the right frontal lobe, which couldn’t be attacked by surgery. It made me feel safe. Like even if the cancer decided to grow rapidly all of a sudden again, I would be in radiation therapy and they would immediately start killing it. I felt as though, temporarily, the cancer was no longer allowed to occupy a tremendous amount of space in my skull and cause problems anymore. It was an incredible sense of protection and safety and I looked forward to each radiation morning. I had the same radiation team as before. They were devastated to see me back. I told them about my feelings about this second round, and they understood. I even asked the radiation oncologist why we didn’t just keep going with more sessions, but apparently the potential side effects from continued higher dose radiation could be more serious than finishing a session and the cancer growing more. I found that difficult to believe, only because I was familiar with the ramifications of uncontrolled cancer, but I trusted him and believed him in the end.

              And so most mornings I would show up to radiation oncology. My team would greet me. We’d catch up a little bit. They knew that I liked Maggie Rogers, and would always put this music on for my treatments. I thanked them and was grateful. I had listened to Maggie Rogers extensively on planes during interview season and found her music comforting, and I gained a similar comfort from having it during the radiation sessions. For each session, I would enter the room, take off my hat, glasses, and jacket, then lay on a rigid plastic table with a jell-mold for the back of my head. The team would apply a warm blanket over me—this was the best part. I love those warm blankets. Sometimes if I’m having a bad day I ask them to put two on me and it is wonderful. Then they apply the mesh facemask that’s molded to my face in order to lock my head into position. The mask caresses my nose and chin and feels very secure—I cannot move my head at all. Then they leave, start the music, and it’s time to start treatment. There’s a large metal disk on some beams and hinges that appears as though it has a laser or something that moves around my head during treatment and presumably fires radiation in a specific plan into my skull. The radiation itself does not feel like anything. Although occasionally I start to get a smell as though something is burning. I still do not know what this is from. I like to imagine that I am smelling the cancer cells dying, which comforts me. After a little while, someone comes in and moves the table a little bit in order to hit different angles with the radiation saucer. They place a pad under my knees as well to make it more comfortable. I am usually able to sleep or relax/ meditate during sessions. And then it’s over. They come in and remove the mask. They lower the table, and I’m free to go. I thank them and put back on all my items. Sometimes when I walk back out to the front desk there is a sign instructing me that I will be seeing the doctor—the radiation oncologist—or will be needing to get labs. Usually this happens on Thursdays. That day there is nothing additional to do. I stop and ask the team if they like Kombucha. They say yes. I’ve been brewing my own kombucha for the last few weeks, and I tell them I would like to share some of it with them. They tell me that they’re looking forward to it. I’m trying to avoid sugar in general, because I read a case study that suggested high sugar in the blood could hasten cancer growth. Since kombucha could be sugary, I felt like I could not drink my own brew, so I was excited to share it.

              The next morning was radiation again. This time I brought one of my new bottles of kombucha, a lemon-ginger one I had made. I was excited for this one because I had used a chai black tea for the initial fermentation, which I had heard could create really interesting flavors. I labeled the bottle before packing it, then left for radiation. When I showed up, I presented the team with the bottle and told them what it was and said I hoped they would like it. I asked them to give me back the bottle when they were done and I could bring a different flavor. They thanked me and told me they were very excited to try it. They asked me about music. I told them Maggie Rogers again. They led me to the room and I finished another round of therapy. Tomorrow was Thursday, which meant doctor and labs. As I left I thanked my team and asked them to let me know what they thought of the kombucha. Incidentally, I feel that I should mention that I only got into brewing kombucha because of my first College Roommate and one of my best friends, Kyle, who began brewing kombucha on his own and shared his brew with me. It was delicious and I was shocked with how much better it tasted than store bought. And so when I started, he guided me through the process. Another thing we could share. I am very grateful for that.

              The next morning I show up for radiation. They ask me how I’m doing. I try to be as honest as I can. Physically I am doing fine, but emotionally I am unwell. I tell them that it’s difficult to know what to do with each day. That I don’t wake up with a strong desire or idea with how to spend the day, and that I worry each night or following day that I have not spent one of my few remaining days in a valuable way. All I want is to feel a strong want or desire with what to do each day. They offer comforting words and say they understand. I’m grateful for the conversation. I feel like this anxiety of living in the present moment has been eating away at me like moths on a rag, and it relaxes me to talk about it. I wonder if anything will ever change with these feelings. I feel as though, as long as someone else knows, whatever I choose will be OK. realize that growing up I never really learned to live in the present moment. I had always lived for the future. I wish that I had learned earlier, when it was not dictated by necessity. Nevertheless, here we were. The radiation team tells me that the kombucha was really good and that they really enjoyed it and were excited for the next bottle. I thanked them. It felt incredible to know that something I made had tasted so good and made such a wonderful group of people happy. They told me that they would have the bottle back next session, so I should bring the next batch then. I agreed. They led me back for radiation. This time I had two warm blankets. It was very comfortable, I nearly fell asleep. The music was the same. I told them that I was working on a playlist for next. They said they were excited for the playlist, because I after two separate rounds of radiation, they thought I had good taste in music.

              The next day I brought a blueberry ginger kombucha, and my playlist. They gave me back the empty old bottle, and thanked me for the next batch. They were sure to mention that it would be OK if I just wanted to listen to Christmas music during sessions as well because each day I would arrive drinking coffee from an enormous Santa Mug that my brother got me for Christmas. Plus, the previous sessions were during Christmas and I would listen to the Ariana Grande Christmas albums every day. I thanked them for the offer, but decided to go with the playlist that I had created instead.

              We did the session. Just one warm blanket this time—it was enough. After the session it was time for labs and doctor. I’m led into a sort of patient lobby. They take my vital signs. Then come around to draw my blood. I present my left arm. I feel like it has been poked fewer times, although both have been poked many times. There is a caruncle over one of my veins, scar tissue from being repeatedly poked. I ask that they draw from anywhere but there. It is painful when they stick the needle through scar tissue. They try twice in the inner elbow of my left arm, but no dice. Then they bring someone else in, and try in the left hand. It’s painful to be poked over and over again. Eventually they ask if they can try the right arm. I say that that’s fine and reveal it. I had been avoiding the right arm because it has my tattoos with friends, and I don’t want to develop scars in areas of future tattoos. This time they go immediately for the right hand, just over the thumb. They get blood. I’m releaved. They finish and apply a bandage. I’m led to a patient room where I’ll see the radiation oncologist.