A Christmas Story
A medicine attending writes about a patient from Cincinnati & a resident from urology
I don’t ward attend as much as I’d like (hard to leave my clinic unattended), but over the Christmas holiday clinic slows down enough and the ward attending schedule is desperate enough, that I often cover a general medicine service.
Last year we had a patient transferred from West Virginia in respiratory failure. He was from Cincinnati and did not know a soul in Charlottesville. After a few days in the MICU he came to us on antibiotics for community acquired pneumonia, on anticoagulants for a new pulmonary embolism, on high flow oxygen, and with a right renal mass that looked bad. Mostly he complained he was hungry. We decided he needed a vena cava filter, a chest tube for a large para-pneumonic effusion, and a nephrectomy. He got the filter, refused the chest tube, refused surgery because it couldn’t be scheduled for weeks, and by the way, he lived in Cincinnati.
We decided to drain his chest ourselves. In my time, in the days of the giants, medical residents did the thoracentesis at the bedside, using percussion and auscultation to localize the fluid. Fluid is dull to percussion, but so is the liver, so is the spleen, and so we tried to give the hemi-diaphragm plenty of space. And there we were, a 14 gauge catheter in the patient’s chest, and 100 cc’s at a time we proceeded to remove two liters of sero-sanguinous fluid. I was in no rush. The patient was not going anywhere. The resident was a captive audience. He and I took turns at the syringe, and the three of us had time to talk. I was curious why the patient was in West Virginia.
Turns out a woman was involved. Turns out alcohol was involved. Turns out poor judgment was involved. We are all human, and there are many ways to end up with a large pleural effusion. Discharge planning should begin the day of admission. The patient’s plan was to drive to Cincinnati and get himself admitted for nephrectomy through an ER. We reviewed his plan. I reminded the patient that his car was in Cincinnati, that he shouldn’t be driving, that he might need some oxygen for the trip, and that his wife, given the circumstance of his absence, was not inclined to either take him home or drive him home. Maybe his sister would fetch him. By that point we had surpassed our pleural fluid goal. The patient tolerated the procedure well, but complained he was hungry.
The urology resident spoke to her attending, and the attending had a colleague in Cincinnati. Suddenly we had a plan. The next day the patient’s room air O2 sats were above 90%. I encouraged him to get out of bed and start exploring the grounds of his new home, UVA Hospital. I gave him some money to go the gift shop to buy a candy bar. On rounds the next morning he had six dollar’s worth of candy on his bedside table-my dollar plus the resident’s five. His sister was there too, looking like a big sister.
The patient returned to Cincinnati. I returned to clinic. The resident went into his subspecialty. This Christmas I am on the wards again.