Two trains and an Uber, it was the same 2-hour commute to start my Friday at my family medicine assignment. My day started the same. Prior to meeting each patient, not having access to patient charts at home, I’d spend a little time reading up about them. At least, that’s how I hoped it’d go. Typically, I had very little, or absolutely no time to research a patient before having to present to an attending that love to start with, “So tell me everything you know about Mr. Wilson.” But, today, it was a rare exception. I knew this patient, in fact, I had sent her to the hospital a week earlier. I wondered what had happened to her.
One week prior, on a Friday, Ms. G, a 42 year-old RN visited our primary care office for what was labeled “same day sick visit.” Her history was significant for migraines. She hadn’t given any real details to the nursing assistant who booked the appointment. She had come in, with one of her daughters, she intended to make a quick visit and then bring her to lacrosse practice. The patient had her daughter wait for her in the lobby. As I took her vitals, I did the standard interview. And though rather reluctantly, the patient finally admitted that morning she experienced unilateral left-sided weakness in both her legs and arms, tongue heaviness, blurry vision, and “the worst headache” in her life. I took enough history to present a case to my supervisor that we should drop what we’re doing and get her ready to get picked up for hospital transport: raise clinical suspicions for stroke, mass, and an intracranial hemorrhage. Indeed, my supervisor did drop what they were doing to see the patient, we talked to the patient together. The patient, with reasonable denial, refused to go to the hospital. She had assumed it was just a severe migraine attack. She, a RN herself, was no stranger to the hospital system. The patient, my experienced than I, was no stranger to Occam’s razor – she knew the simple answer with the least amount of coincidences is usually the correct answer, thus given her history of recurrent migraines her theory of migraine attack held a lot of water. To the patient, I watched the nurse practitioner plead her best case of why she shouldn’t ignore her symptoms. I watched the patient skillfully, and thoroughly, brush off all of the medical advice. I was left alone with the patient, there was some awkward silence. I thought about not saying anything, her idea seemed logical, easier, and the patient gets what she wants: go along our day as if nothing happened. But, somehow I blurted out, “I know chances are you’re right, and I know this is a lot, but there’s a legitimate chance there’s something seriously wrong. And, I think you should go to the hospital. You need imaging, and you know that.” She didn’t say anything. Another awkward silence. She let out a sigh, and said “I know.”
So, I was somewhat excited to see this patient a week later. If I was right, awesome, I hope something treatable came of it. If I was wrong, she wouldn’t be admitted, she’d be hit with a nasty ED bill and potentially a bucket-load of imaging. I asked my supervisor if she had the paperwork from the ED on the patient, because while electronic health systems are usually updated into our systems hers was not. She gave me a little packet of paperwork and told me to read it before seeing the patient. Eventually, I got to the radiology report: 4x4x3 cm brain mass.
After reading the report, I called the patient to a patient room, we then sat down together. I asked how she was, and how much she knew about her admission and diagnosis. She was frustrated, angry, shocked, and overwhelmed. Who wouldn’t be? Being with her, in her dark moment, I remembered why I got into medicine in the first place. As I listened to her vent about the shock of the diagnosis, handed her tissues, and reviewed records with her, I remembered my goal is medicine is to help people continue on with their goals. To see people continue to be with the people they love, with the people who love them, and the people their love has yet to reach. This patient, a mother of three, wife, colleague in medicine, and most importantly a person, had a lot to live for. Indeed, the first visit with the patient involved physical medicine, while the second visit was a psychiatric mental health visit.
The visit ended, the patient and I most pick up the broken pieces, she went on with her life, and I went onto the next patient. That’s the strange thing about seeing patients, you see a tragedy, but you must see the next patient as if you’re unaffected and emotionally immune – the emotional Etch-a-Sketch. Everyone patient wants someone who cares, but not so much that it detracts from their care. And with that, my back to back visit transitioned from cancer to benign urinary tract infection. Only in family medicine could you go from talking about mortality to talking about the merits of cranberry juice.
My family medicine rotation is over, about 140 patients later, a wallet a lot lighter from transportation fees, another shelf exam on the books, and I’m two weeks into my Radiology rotation.
Best Wishes and Happy Thanksgiving