The Human Touch 2013 - University of Colorado Denver

On the Front Lines
Evelyn Brosnan
It was the second week on my internal medicine rotation and the senior resident suggested
that I pick up a new overnight admission as a patient – “the guy with the DVT in his arm.” I
inquired about his name. It was Garry, “with two Rs”. My resident remarked that this case
was a bit straightforward but that I’d learn about blood clots and managing DVTs.
Garry was grumpy when I went to see him. I was the latest in a line of too many
people who had already asked him the same questions. On top of that, his left arm
had ballooned up to twice its size, was completely tense, and hurt enormously to the
touch. I pulled up a chair and explained that it was helpful to hear the story directly from
the patient and often things become clearer this way. He just looked up at the ceiling
and answered my questions tersely without looking at me. I tried to be gentle with my
physical exam and having accomplished what was necessary for rounds, I told him we’d
be back as a team and headed off. It felt awkward, intrusive and that I was unwelcome. I
wondered myself if, as a medical student, I had anything signifi cant to offer.
Later that day, I returned to check on him. He warmed up as we chatted, telling me all
about the antics of his terrier dog that he loved. Then in a twist of the story, he suddenly
announced that his son would kick the dog viciously whenever he visited him; this same
son had since ended up in jail. I didn’t expect that. More pieces of his life emerged –
he had been a roofer, prior to that he was in the navy, was now divorced and lived by
himself with his dog. He told me about living with a heart that wasn’t pumping so well
(I knew from the medical record that his ejection fraction was 29%). He had many comorbidities.
He also had sleep apnea, but did not like to use the CPAP machine at night
since it made him feel that he’d suffocate. We talked a good deal about all that.
But he was here because he had a DVT in his upper extremity and we were giving him
heparin until we bridged him to warfarin and he could go home again. The next morning, his
ex-wife was in the room and Garry introduced us. She’d flown in from another state. I was
surprised. We chatted and she seemed to care quite a bit about him. On exam, his arm was
softer and less painful to move. I’d learned that if his INR after 48 hours was therapeutic we
could switch him completely to warfarin, which we did. Things were going according to plan
and we’d likely send him home the following day. I noticed that hospitalists shared the same
vigilance about the “dispo plan” as emergency room physicians.
The following morning, I arrived to discover that Garry had needed 12L of oxygen nasal
cannula overnight. Naturally, we wondered about a PE but the CTPE scan showed no clots in
his lung and his INR was therapeutic. He remained stable and his arm continued to improve.
Late in the day, on my own “rounds” of my patients, I swung by Garry’s room and chatted with
him for a bit before I went home. “See you tomorrow,” he said as he waved me off.
At sign-out the next morning, the overnight team relayed that Garry had developed breathing
trouble overnight, had to be put on CPAP to maintain his oxygen saturation and had been
moved to the step-down unit for closer monitoring. A chest x-ray showed significant
occlusion in his right lung and he’d received antibiotics. I went to see him. He was not
well, but could still communicate through his CPAP mask. I commiserated with him since I
knew how much he hated the mask, but tried to encourage him by sharing that he needed
it currently to maintain his oxygen levels and explaining our plan. As I was doing my physical
exam on him, he suddenly grasped my hand, held on tightly and didn’t let go. I looked at him
closely. His eyes were shut and I sensed he was scared. “Are you afraid Garry?” I asked. He
nodded, without opening his eyes and squeezed my arm even more. I tried to reassure him
and also told him, “We’ll take good care of you Garry. “ I genuinely meant it.
On rounds, we discussed his case at length, but we still couldn’t explain exactly what
was going on. We were concerned about his decline and wondered if a bronchoscopy
might be in order. On consultation with the pulmonologist, we decided it was too risky to
do it on the fl oor, so we moved Garry to the care of the ICU team. Next morning, since
he was no longer on our team, I didn’t round on Garry, but wondered how he was faring.
I planned to go by the ICU and check up on him. We were on call that day and our
roster got full quickly. I was so tired at the end of the day that I left without going by the
ICU. That night I had a dream about Garry – he was thrashing about the bed in a CPAP
mask, struggling to breathe. I awoke surprised and unsure what to make of all that.
Our team had our hands full from the get-go the next day, but I fi nally had some time in
the early afternoon to write my notes. As I was sitting at the computer, my intern stopped
at the desk and announced, “Garry just died in the ICU. His condition worsened
and they decided to do the bronchoscopy on him, but he coded in the middle of the
procedure. They tried for 20 minutes, but they couldn’t get him back.” I slumped into the
chair, stunned. He came into hospital for a DVT in his upper arm and now he was dead.
All I could think about was he gripping my hand so tightly, and me telling him that
we’d take good care of him. •
PG 26
PG 27