The cost of growing

At 6 am on Friday, I was my team’s first to arrive. A new patient had just been admitted, he was Chinese, and he had a neurological complaint. I immediately jumped at taking his case because I knew that, even as a med student in a strange intermediate stage of education, I could actually help.

Oh boy, acute left-sided paralysis following a seizure, on top of a messy medical history. It looked like Todd’s paralysis, where someone is temporarily half-paralyzed after a seizure, but we needed to rule out the king of acute hemiparesis: stroke. The earlier CT scan was clean, but the radiologists hadn’t read the MRI yet. I knew the patient’s clinical picture and where in his brain to look for a stroke, so I read his scan to reassure myself that it wasn’t a stroke before heading in.

When a worried Mandarin-speaking family member saw that I was a Chinese-speaking white-coated person, he urgently ushered me in to help. The patient was hysterical, with his left side unmoving and right side shaking wildly. While comforting him using my elementary Mandarin, I performed a deft neurological exam to confirm that the left paralysis was real, the right-sided movement was a somatic pseudoseizure, but some trace twitching was actually a residual seizure.

After calling the neurology consult, I presented him to the medicine team. Once we ordered the right meds, I helped the nurse administer the antiepileptics and watched as the seizure activity dissipated. I reconciled what medications he was actually taking and elicited further history from family. In between taking care of my other patients, I returned regularly to perform serial neuro exams, which were gradually improving.

Throughout the day, I kept the family updated on the proceedings, as families are often left in the dark as doctors work behind the scenes. In half Mandarin and half English, I spelled out the names of the drugs for them. They had been so scared, seeing the patient sleeping in a drug-assisted stupor, not sure if he’d ever walk again. As our diagnosis of Todd’s paralysis solidified, I explained to the family the prognosis: we expected him to return to near baseline within a day. I helped them look up Todd’s paralysis on their phones. I did the medically legally safe practice of using language like “we’re pretty sure” and “most likely” and “should be,” but I reassured them it was going to be okay.

I felt so useful! The patient received better care because there was a English-Mandarin (kinda) bilingual medical student who can (kinda) read brain imaging and (kinda) perform legit neuro exams who was willing to perform hourly neuro checks on a general medicine floor. Usually, with medicine I’m just a (mostly) obtrusive and (mostly) useless student that isn’t allowed to order labs and meds or write notes. This was the first time I felt comfortable supplanting the intern. That evening, I left the ward quite fulfilled.

While doing non-hospital things over the weekend, I kept wondered how he was doing. It had been such a dramatic presentation, and an equally dramatic recovery was expected, and I wanted to know. Nonetheless, I resisted logging onto the system at home over the weekend because we should have boundaries, right? Monday morning, the first thing I did was check his chart.

Uhh, why is he in the ICU?!


 

Apparently, over the weekend, the paralysis persisted, and he got progressively more agitated and uncontrollable. Given alarmingly worsening mental status, he was upgraded to intensive care. I pulled up his repeat MRI and OMFG.

His brain was on fire. The entire right hemisphere lit up bright on MRI, wildly inflamed. There’d been no sign of it two days before, and now it was everywhere. It covered parts of the cortex that command left-sided movement and sensation and his personality, but in an atypical disseminated distribution. This wasn’t just epilepsy nor a stroke but something much more sinister.

(For you medical people trying to diagnose him, sorry, I altered/censored important history because HIPAA, because this is a real person currently admitted with an unusual constellation of diseases and, like, case-report level rarity.)

When everyone else arrived on Monday and heard of what happened, we all shared the same “holy shit what happened” reaction. We were all shocked and dismayed. Even though he wasn’t on our service anymore, we reviewed the case and weekend events with something that resembled personal investment. We lamented about how there was no way to foresee this progression from postictal paralysis to full-blown encephalitis. We ultimately moved on after the closing comment “this is a cool case, yeah? We should write it up.”

But I had additional mixed feelings. Sure, I performed the initial assessment, but the attendings all confirmed my findings before establishing the plan. My real contribution was that I was there first, that I was the one talking to the family and who they saw most. I was the face of the medical team. I reassured them this would all be over and they’d walk out by Monday, and I was so, so wrong.

I visited the patient and family in the ICU. The patient was thrashing around in the bed, being managed by the ICU nurses, too altered to recognize me. I dreaded facing the family, but they didn’t ask me to apologize for the misinformation or false hope. They understood. We were on the same side, rooting for the patient and hoping for a swift recovery.

I don’t feel guilty about not diagnosing him. We all did. In fact, this time I was actually limited not by my medical incompetency but by the disease itself. But what bad timing for my first complex patient to end up having some rare devastating encephalitis. (Needless to say, rotten luck for him…) I was feeling all proud of my progression as a clinician, and then the misfortune of illness struck.

This week felt different. I’ve independently evaluated and discharged three patients: a lady with a CHF exacerbation, a man with an asthma attack, and a woman with a GI bleed. In each case, they got to go home sooner because I was free to advocate for them and attend to their follow-up and paperwork. I’m bolstered by newfound confidence but simultaneously so much more wary of medicine’s deadly mystery and unpredictability.

Every morning, I type in his MRN (which I’ve now memorized) to follow his progression. All five teams following case are still trying to figure out what on earth is happening. In between caring for my current patients and attending lectures, I drop by the ICU to talk to the family and see how he’s doing. He’s better, but he’s still enduring encephalitis hell.

Now I understand why all doctors, no matter how far in their careers, remember patients they met early on. Every instance of stepwise growth in your life as a doctor will correspond to the illness and life of another person. Each poignant lesson will be accompanied by the memory of the patient who taught it to you. They’ll haunt you.