Wrestling With a Patient


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“Lord, I pray that you would help me see my patients the way you see them.” This is a prayer that I prayed from time to time during my junior year. Just recently, I have been reminded of this prayer by a friend and it turned out to be tremendously helpful in processing one of my more difficult patient encounters.

A patient with a genetic disease presented to the ED with pain, which is a fairly common symptom of her disease. She frequently visits the ED requesting IV analgesics and would attempt to leave with IVs in place. This time, she did the same thing again. There was concern that she may be addicted to opiates and intended to keep her IV for drug administration, so I went to her bedside and tried to understand her thoughts. After I listened to her thoughts, I explained the causes of her pain, the need to learn ways to manage and prevent pain, and the importance of following up with her primary physician. She became less guarded and tearfully shared that she felt no one really cared about her. She eventually agreed to have her IV taken out and go to follow up visits. With satisfaction, I gave the attending the good news and brought back the discharge papers. However, the patient changed her mind and refused to have her IV taken out again. She insisted that her pain is not better and if she was not going to get IV morphine, she would re-admit herself or go to a different ED. I explained we could not give her what she requested and she could not keep her IV, so she said she was going to pull out the IV herself. She had an external jugular IV placed because she was a hard stick, so out of concern for an air embolus, albeit most likely harmless in this situation, I recommended that she lay down. However, she refused to lay down, and would not let me place gauze over the IV site. She shoved my hands away every time I tried to place gauze over her IV and we were essentially wrestling back and forth for minutes. Right before the IV tip was pulled out, I was able to put gauze over it and tape it in place.

As I reflected upon this encounter at home, I realized that I really cared about this patient and wanted the best for her. I felt disappointed that she did not take my well-intentioned advice that was meant to help her. Then I realized how heartbroken God must feel when His children whom he cares and loves deeply disobey His commands that were meant for their good. I was not angry at her, but sad that she was too fixated on what she wanted in that moment and could not see a better alternative. Perhaps in many ways, I am like her in God’s eyes. I have desires that I am fixated on. I also have disobeyed God despite His wholehearted intention for me to do what is righteous. I have broken God’s heart many times. Despite my ways, God is gracious to those who repent and promises eternal life, delivery from sins, and refuge for the broken.

This patient encounter started out disheartening but I definitely learned from it. Now, if I see the same patient again in the ED for another pain crisis, my prayer would be “Lord, I pray that you would help me to treat this patient with the same kind of grace and forgiveness that you demonstrated to me.”

Lessons of the Clinical Year (MS-3)

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Some time in freshman year, we were told that our patients are our teachers. It made a lot of sense, especially in the context of anatomy class where we studied the human body through working with cadavers. Somewhere along sophomore year, buried under review books and lecture material, I slowly forgot that valuable perspective. Now, more than midway through junior year, I am noticing a new appreciation for my patients as teachers. I have pieced together several valuable patient encounters that left special impressions. Here is what my patients have taught me:

You can find strength in places you expect the least

In my hand is a list of children’s names. Next to their names are words such as ‘depression’, ’suicidal ideation’, ‘sexual abuse by uncle’, or ‘physical abuse’. However, in front of me is a group of beautiful children sitting quietly in a circle. One is saying that he wants to be a professional football player and get drafted to Missouri University. Another wants to be a video game designer. In a different occasion, these children are laughing while playing Pictionary. It’s heartbreaking to think about how much pain and sorrow each one of these young children have gone through and yet, they laugh, joke, and behave almost like a regular group of children. They carry such dark pasts with them while at the same time, demonstrate so much hope and potential. Their resiliency is absolutely amazing to me.

Pray with patients when you sense the Holy Spirit working in you

A man was seen in clinic for a referral for an adenoma found on a colonoscopy more than a year ago. He had been referred to a surgeon in the past who wanted to do a repeat colonoscopy. On the day of colonoscopy, he found out the procedure was cancelled by his insurance because this surgeon was not covered by his insurance policy. Frustratingly, the insurance went back and forth for a year before he could have another appointment to address this tumor. Fortunately, the surgical oncologist I was working with was comfortable with attempting to remove the tumor through colonoscopy first and is having a colonoscopy scheduled right away. I was happy for the patient and I felt the Holy Spirit bidding me to pray for this man. So right as the visit ended, I asked for his religious background, got permission, and held his and his wife’s hands as I prayed for a smooth procedure as well as praising God for progress in this uncertain stage of his illness. The second I finished praying, this man stood up and hugged me firmly. I was taken back by surprise by his hug and seeing his wife tear up. I realized there was a reason I felt I should pray for them. The prayer really addressed their burden and worry for the past year since his diagnosis but nothing was done about it. It was a huge weight lifted off of their hearts and I was blessed by their joy.

Prayer is powerful for the patient, but sometimes even more so for the physician

A man in his 70s is laying in bed, looking sullen and depressed. His cirrhosis has caused him to have ascites and pitting edema up to his thighs. He is so fluid over-loaded that he is seeping serous fluid from a small scratch on his flank, soaking his bed sheet. Every morning, he greets me with a gloomy undertone. Maybe it’s because his renal failure keeps worsening and he started on hemodialysis. Or it could be that his new cellulitis at his IV site is too painful. He had been in the hospital even before I joined the medicine team. Just a few days before I was leaving for Christmas break, he commented that I fortunately do not have to be here anymore. Upon hearing that, I knew he was feeling bitter about his long admission and deteriorating health. I felt my chest tighten up because I felt a lot of sympathy for him and I felt like I was not doing anything for this man.

For the rest of the day, I felt gloomy to the point of being depressed just thinking about how this man will spend Christmas holiday in bed while the rest of the world is celebrating. I decided to write him a Christmas card and I gave it to him on my last day. I also prayed with him, asked God to heal him, give him peace, and to help all of his providers to take good care of him with the hopes that he feels cared for and encouraged. After I finished praying for him, he appeared comforted and more cheerful, but I was on the verge of tears. After I bid him farewell, I hid myself in the closest bathroom for a few minutes and allowed tears to pour down my face. I do not fully understand my emotions at that time. There’s been times when prayers moved my patients to tears or immense joy, but I have never been brought to tears by my patients. Perhaps the Holy Spirit was moving in me and I truly empathized with him. Perhaps I was unconsciously saying farewell to someone who had become a friend and I knew I won’t see him again. Whatever it was, I truly hope that the Holy Spirit touched him on that day, comforted him, and sparked an interest in Christ. As for me, I learned that when I pray with patients, I experience the satisfaction and fulfillment of knowing I had done everything I can to take care of a patient’s physical and spiritual wellbeing.

Change is possible no matter what

“I take full responsibility for cheating on you 7 years ago”, he said genuinely as he read his letter to his wife to the other men sitting in a circle. As he continued to read a list of things he takes full responsibility for, his voice started to choke slightly and had to pause a little. I have heard love letters, confessions of love, and even wedding proposals, but so few are done so honestly and genuinely that you would not think he’s exaggerating or making things up to sound good. On the addiction & chemical dependency unit, there are many individuals struggling to quit substance abuse and relapses. It is difficult for me to break certain bad habits in my life, and I can’t imagine how difficult it must be to quit addictive substances and remain clean in the face of temptation for the rest of life. However, it is also in drug addicts that I also find the most spiritually passionate Christians. Romans 5:20 reads, “but where sin increased, graced abounded all the more.” The more wrong a person has done in his life and desires to change, the more he appreciates forgiveness. As I listen to this man’s letter, I realize that I, too, have many areas for growth and a need for forgiveness.

There are so many special patient encounters in the clinical years and I feel these are what give meaning to the practice of medicine. Yes, there is much value in practicing evidence-based medicine and in ongoing break-through research. I do not want to minimize the intellectual aspect of medicine as that is absolutely necessary. At the same time, I am reminded of 1 Corinthians 13:2, “If I have the gift of prophecy and can fathom all mysteries and all knowledge, and if I have faith that can move mountains, but do not have love, I am nothing.” A physician with perfect knowledge but no expression of compassion and kindness to his patients is missing out on some of the best parts of medicine. There’s so much emotional healing and sense of fulfillment in holding patients’ hands, praying with them, getting to know them, and encouraging them. This applies to any aspect of life as well, but being in medicine is a very convenient position to do this. I hope all Loma Linda students will try praying for their patients at least once during their training. We are made with a yearning to be loved, to be cared about, and nothing makes us happier than being in a loving relationship with others. I am truly glad that I will be able to care for patients for the rest of my life and I thank God for this unique environment here at Loma Linda.

Coma: A Pause Between Life and Death

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There was a flurry of activity surrounding his body – buzzing sounds, blinking lights, hands flying in and out of view. There was shouting. There was a panic. Then there was a silence. The noises and commotion had not stopped, but the patient’s heart did. An eerie, ringing silence muffled the background noise––death was knocking. The stillness that comes from the awe of gazing upon the grandeur of death’s door was broken by a team of physicians who came crashing into view. They fought to save his life. And after seven minutes, the enemy of longevity, death, retreated. The man’s pulse returned; the physicians had saved his heart. However, they were not able to save his mind. His brain had spent too much time without oxygen, and the anoxic brain injury bell toll rang. He was standing on the edge of a coma.

Twenty-four hours later, the man showed little signs of improvement. Repeated testing of his brain-stem function gave little signs for hope. He wouldn’t speak, open his eyes, or move his limbs. He was estranged from his sons, so they debated over the phone from different cities about keeping him on a ventilator or taking him off. This man who once had hopes and dreams was now alone, trapped inside his mind. And then, the next morning, his niece showed up at the entrance to his room.

Hearing her uncle’s story, and seeing his condition brought tears to her eyes. As we explained the circumstances and discussed the expectedly extended trajectory of his recovery, she grabbed his hand gently and looking at us with watery eyes said she knew he would get better. He was showing minimal signs of recovery, but she had found reason to believe in spite of what she saw. And though it was touching to hear, it seemed as if time did not agree with her.

Days went by and the man did not improve. His sons could not come to an agreement on what to do with him and his niece could not relinquish her optimism. Every morning she sat at his side, his hands clasped in hers, whispering words of encouragement. It was something worth marveling at, really––seeing hope thrive like a single flower in such a barren valley of despair.

It was a privilege to witness such courage, and an even greater privilege to see her courage rewarded. The next day the man began to twitch when his nail beds were pressed. The following day his eyes opened. The day after that he began to turn his head when his name was called, and the day after that he began show responses to simple instructions like “raise your eyebrows” or “turn your head”. Within days his breathing apparatus was removed, and he was beginning to form words again.

The next morning when I examined him, he had taken leaps and bounds overnight. With effort, he was able to follow almost all my instructions, displaying remarkable gains. He was forming sentences and it seemed as if he was the most aware he had been since I first saw him. He was possibly more aware than he would have liked to be. With the return of his cognition came the full realization of his condition––he could barely move the lower portions of his body. When I asked him to raise his legs or move his feet, he was still having significant trouble. As his mind grappled with the reality that he still could not move his limbs at will, he looked at me with a pain expression and tears started running across his face.

I didn’t know what to say. I wasn’t expecting him to cry. But his aged face stayed focused on my confused one. “Don’t lose hope.” I fumbled. “It may take some time, but you can do this.” I was at a loss for words and that was all I could scramble for. I grabbed his arm with intention, “Whatever you do, don’t give up.” He slowly nodded. He was being prayed for.

When rounding with the attending and team three hours later, I found the man was sitting up in bed seconds away from practicing walking with a physical therapist. My jaw was scraping against the floor. What is this power that moves over human life? What is the source of this hope, this courage, this strength that mankind shows in times of sorrow and duress? Who can reach into the depths of a man’s mind and lead him back to his loved ones safely? How could someone stand so close to the brink of death, and so quickly find his way back to life? Was this man’s entire recovery simply attesting to the magic of medicine? Or had I glimpsed into the eyes of a miracle? Was this the heart of the ministry of healing?

The room was lighted with smiles and laughter. The man was moving. He was speaking intelligibly. And what else would be some of his first words other than a quip against the US president? I smiled and thought of these words, “By prayer the sick have been encouraged to believe that God will look with compassion upon them. A ray of light penetrates to the hopeless soul, and becomes a savor of life unto life.” (EGW, Adv. Review and Herald, 1900).

Snow from the Sky

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“Wow! It’s snowing from the sky!” A novelty for those of us that only see snow spraying up from the ground at ski resorts. My husband and I (we got married over Christmas break) traveled to Kettering, Ohio for our inpatient internal medicine rotation. We had an amazing experience, learning lots and meeting many new people.

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On our flight over, we met three cool fourth years––Chas, Amanda, and Stephanie––who helped show us the ropes on how to prepare for rounds. Julie Dicken had everything we needed from food, transportation, housing, and our schedules organized and readily accessible. Dr. Fershko also met with us on our first day and was an enthusiastic proponent for our education. The residents also kindly took time to go over our notes and give mini-lectures, and our attendings guided us through patient management and relations.

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Throughout our stay, we saw a diverse patient population from drug seekers and ruled out chest pain to AML and SLE. We experienced patients who loved us and those that might have loved us if we had given vitamin D or “dilala” (dilaudid). We were able to celebrate with patients that recovered and for those that passed away, tried to stay strong for the families left behind. Our academic knowledge and interpersonal skills drastically grew in three short weeks.

All too soon, we were heading home. Bundled up to avoid the 5 minute frostbite (Anthony looks better with both ears), we drove through the snow, falling from the sky, our white Christmas for the year. We were sad to end our great experience and say farewell to our new friends.

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4/10

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Medicine can be unforgiving. Most days, it demands your all – all your time, all your attention, all your strength. And it demands it for better or for worse, for richer or for poorer (and it can make you very poor long before it makes you rich). It demands your all in sickness and in health. In moments when you feel like you are at your worst, it still expects you to preform at your best. And when you need to be alone to lick your wounds, it will throw a dozen people in your way who expect you to fix theirs first. IMG_6535

I thought this as I sat cycling through waves of pain while I was sitting in on a required group session for my clerkship. I looked at a clock. It was almost 9pm, just a few hours after having some of my wisdom teeth wrenched from my face and a few hours shy of my birthday. “Why on God’s green earth am I not in bed resting? Half my face feels like it’s being peeled off with needles and I can’t move my mouth.” When I realized I was talking to myself, I paused and took at my surroundings.

I was at a meeting for family members who had been affected by a loved one’s alcoholic tendencies. Many men and women were gathered to share stories of hope and to give encouragement. They refused to veil their inner pain, but instead insisted on sharing it with each other – and in doing so, they seemed to find new strength. They built for themselves a support group that helped them bide the tides of tears and tragedy that would have otherwise caused them to lose their way. I placed IMG_6533my hand on my face and tried to smile (though I’m sure it came off as a grimace).

I smiled both because I was touched by their strength and because I realized I have my own version of that support group. We aren’t struggling with being alcoholics, or with being family members of alcoholics per-say, but we are battling through our own life-changing addiction – medical school. And on the days when this educational drug seems to take away
more than it gives, that rag-tag “support group” of friends comes kickingIMG_6532 the doors down to bring encouragement. Today, it came in the form of warm soup and empathetic hugs. A few nights later it came in the form of an 8-12pm birthday party (when all the attendees had to be awake for surgery rounds by 3.30-4am). A few weeks later it came in the form of a weekend ensemble. And every day it comes in the form of obstreperously hilarious texts, indelible adventures and prayer.

There are days when medical school sits on the edges of wonder and IMG_6539disaster. There are days when medicine trifles with awe and with youth. There are days when medical academia seems to be unforgivingly
demanding. Yet on those days, when friends come clamoring to the rescue with simple reminders of selfless love, I’m reminded that every hot-mess expectation or situation that medical school throws my way is being tempered with a Creator’s care.

If one falls down, his friend can help him up. Ecc. 4.10
A friend loves at all times. Prov 17.17