I haven't had any good blogging ideas for a while. But since I've posted all of my rotation writings this year, I had been expecting to post my upcoming medicine paper. Thing is I haven't made it yet- but its only supposed to be a page long (double spaced of course...), and sure enough keeping reflective writing that short will easily be the hardest part. So I'm going to write one freely here- then edit for submission.
My assignment-
Reflective writing differs from other kinds of writing in
that it allows the writer to express his or her thoughts and feelings about
something (an experience, a text, a film, etc).
By the time I finish your paper, I should have a good idea of what your
experience with one of your patients was like, how it impacted the care of the
patient, and what it taught you about your future work as a physician. Remember the goal of this writing is
reflection and the subject is one specific, meaningful patient experience you
had while on the Medicine Clerkship. I
want to know what you are thinking!
There are 3 parts to this paper:
- Summary
of the specific doctor-patient experience/encounter. Tell the story. Do not interpret here.
- Exploration/interpretation
of the possible meanings of the event.
For example, how did this event contribute to your understanding of
the patient? What did you actually
experience, feel or observe?
- Description/prediction
of how the knowledge you gained from this encounter can be used in the
future for your profession. For
example, what implications are there from this experience that will impact
your work as a physician in the future?
What did the experience teach you?
How will it make you a better physician?
I believe the description of the assignment itself is about 2 pages double spaced.
It doesn't say in this description, but it is suggested in other course documents that this paper is supposed to reflect on a palliative experience, but not necessarily one from my palliative med week. So as I try to recall patients I could potentially use, there are plenty that come to mind, most of them actually from my last couple weeks of the rotation. It's hard to pick one, but I will probably pick the one I followed the longest...
The patients that I find the most interesting from a learning standpoint were those which were delirious, demented. I had three that I would like to choose from... JW, PW, RG.
JW
61 woman who had a kidney transplant something like 15 years ago. She came in because of confusion, or altered mental status, and kidney injury. We did the full work up for all typical causes of delirium in a patient like this, but all work up was negative. No infections, tumors, strokes. Discontinuing many of her meds did not do the trick to clear her up. So in the hospital she stayed for 4 weeks, the exact 4 weeks I was at this hospital. She waxed and waned in her confusion, a quality typical for delirium. At her worst she was calling out, saying that she was trapped in her car and somewhere in Lexington. In reality, she was dangling her legs off the side of the bed, tangling them in the bed rails, staring off into the air. She was given antipsychotics for a week or so, but they seemed to only knock her out and not improve her confusion. She did improve the most in the last week, but only to about the level she was at admission. My attending decided in the end that it must be a psych issue that she has just kept masked well for a long period of time.
We decided to consult palliative medicine at the beginning of the last week. Largely because she was not eating or drinking hardly at all due to refusal, and she had made it clear in the past that she would never take a feeding tube. Consulting palliative for a patient in her situation was very baffling for me. You consult palliative usually when you know someone is dying. We had no idea what was wrong with her, we just knew that she had already denied the types of care she needed to get better (feeding tube, dialysis for her worsening kidney function due to dehydration, blood transfusion for her worsening kidney-faulted anemia). It was one of those end of life care situations that should make someone paranoid to make those life-prolonging-care decisions: a patient unable to make her own decisions during a hospital course that should be totally fixable, but previous refusals of care wishes prevent someone for bouncing back. If she dies as a result of this condition, her cause of death will be something like renal failure due to dehydration secondary to altered mental status.
PW
88 year old woman. My experience with this woman was brief, but I did learn some new things from her. She was a patient of mine during my palliative week, and she was consulted due to "terminal agitation." Agitation can kill you, huh? That's not something we've ever learned for step 1 boards... In more understandable terms for me, her diagnosis was "end stage dementia." She was sleeping more, eating less, and had become combative in her confusion around others. During psychiatry, I heard for the first time that dementia is actually a terminal disease. I hadn't known that previously, but those who get it usually die within 5 years or so. I learned during this rotation that dementia has 3 types, two that are neurological, and the third is simple Alzheimer's. And most people who have dementia don't just have dementia, they have Alzheimer's dementia. The word is just cut short. There is no such thing as plain dementia.
Everyone with delirium/dementia thinks the year is in the 1990s. At least that was my experience.
RG
92 year old woman. It may not be easily assumed, but dementia and delirium is all over the hospital. Hold for Peds I've probably had dozens of patients in these states. You get used to them though. Every morning you see them, you go ahead and assess whether they are still confused, then you tell them you are going to take a listen to them and move on. So when we visited RG on Wednesday, it didn't feel overly imposing that the fellow, my classmate, and I all did focused physical exams on this woman. She was awake and responsive to stimuli, moving slowly and deliberately, but was not following commands, acknowledging our presence, or speaking. When I first walked into the room during the fellows exam, he was working to have her release a tight grip on his index finger, before moving on to look at her feet. My classmate and I both did exams on her because we needed a patient to demonstrate a physical exam on so the fellow could fill out eval forms for us. We could not do very good ones without her cooperation, but we went through the motions anyway.
The next day a code was called on her during our morning rounds, and I was the one that went to the unit to see if it was her. As she was the day before, she appeared to have no visitors, but instead the typical 15 or so response staff surrounding her, attempting to intubate, doing compressions, on her plank-like, exposed and bony frame. We were a consult team for her, so I am not certain of her complete course, but my attending said she was likely septic all along. I feel bad about doing the physical exam. But maybe I feel worse that she was not DNR.
I know I didn't address all three criteria for reflection in each of the patient stories... but I probably could once I pick which one I decide to use... obviously RG or JW, probably JW. I'll take thoughts if anyone wants to give. I'm supposed to submit by March 19 I think.
