By Hussayn Alrayes, DO Candidate 2016
Michigan State University College of Osteopathic Medicine, East Lansing, MI
Names and details have been changed to protect the identity of the parties involved.
I was only a week into my first internal medicine rotation, and made sure to wake before the crack of dawn so that I could arrive at the hospital by 5 am. My senior residents expected a lot out of me, and punctuality was no exception. After shrugging off the mist from walking across the parking lot to the hospital’s student lounge, I sat with my residents and medical student peers to sort out our patient assignments. Each of us would be assigned patients based on their reasons for admittance to the hospital—also known as their “chief complaint.”
The first case I received was that of Mr. James, who suffered from shortness of breath. This would be a relatively routine consultation for me, as I had developed a robust understanding of the cardiovascular and respiratory systems. Next was Ms. Stevenson, whose ailment was described as “lower limb swelling.” This could have been any number of things, but I immediately began to build a list of possible causes based on the information in her chart. Finally, the patient I was hoping to avoid was assigned to me: syncope.
Syncope—a term used to describe a transient loss of consciousness—was the bane of my existence, mostly due to the ambiguity of such a complaint. In medicine, the list of possible causes for fainting or syncope is almost endless, but one of the more common reasons is lowered blood flow reaching the brain. This may seem simple enough, but then comes the task of identifying the various possible causes of decreased perfusion to the brain, along with all the non-hypoperfusive causes of fainting. On top of all of these considerations, an epileptic episode, which can mimic syncope, can turn what seems to be a simple diagnosis into a murky one.
My patient’s name was Janette. I made my way down to the emergency room to gather all of what I needed to know about Ms. Janette, and upon a thorough review of her chart, I decided to pay her a visit.
Janette was a frail-looking woman in her mid-70s, laying in her bed with a deep bruise over her left brow, and some bruises over her arms—likely the result of having difficult veins for the nurses to start an IV. She gazed at me, and a warm smile stretched across her face. I introduced myself, voice still a bit shaky from my inexperience with patient interaction, and we began to talk about what happened to her. According to her, she tripped over a rug in her kitchen and couldn’t react in time to properly brace herself, hitting her left brow on the floor. She lost consciousness, and her daughter found her on the floor minutes after the episode. The fact that she had Alzheimer’s disease made sense as to why the story she was telling me was different from the story she told the paramedics.
She wasn’t trying to lie, but instead was subconsciously trying to fill in details of an event that she could no longer fully remember. After she finished recounting what happened, I posed her with the three questions we ask patients to assess their mental status: “Where are you right now? What year is it? What is your name?” She could only correctly answer the last.
Over the next few days, Janette was worked up from head to toe. CTs and MRIs were done to rule out any neurological cause of her fall, along with an EEG to rule out any seizures. The cardiology team worked her heart up and down, but came back with no explanation. Throughout her stay, every morning at 5 am, I would pay Janette a visit. Every time I entered her room, she smiled the same gentle smile she had given me in the emergency room, and would always greet me as if it were her first encounter with me; because to her, it truly was. I patiently reintroduced myself every morning, and calmly explained to this frightened woman why she was in the hospital.
One of the issues that people in the advanced stages of Alzheimer’s disease struggle with is slowed speech, along with the inability to remember basic words and names. In a hospital setting, a patient with this issue can be frustrating, particularly because there is pressure to see all patients in a limited span of time. Given that doctor-patient interaction is never monitored, being rude to this woman would have been all too easy. The thought of being abrasive toward her can creep upon the mind in these circumstances, especially given the knowledge that she would never be able to remember or recount the details of our encounters.
Anonymity can be a nasty thing sometimes. Closed doors have a way of enticing our darker thoughts to come forward, and in the midst of circumstances with no oversight or accountability, our moral compass can often be tested. In these situations, the tendency to favor one’s self-interest at the expense of others is quite tempting. As human beings, we are hard-wired to pursue our own selfish satisfaction, often favoring our own desires over doing what’s right for others. This results in a precarious sense of reduced accountability for our own actions, giving us free reign to indulge in more primitive behavioral tendencies.
Looking back, I am glad I chose otherwise. In my interactions with Janette, the subtle affinity to empathize with others proved more powerful, and it kept me from being abrasive and cold. Perhaps it was her sincerity, her smile, or how pleasant she was to speak with at times. Maybe I just don’t have that in me, and my selfish thoughts stayed as thoughts, and would never mobilize themselves into action. Whatever the reason, what I do know is that it was important to keep treating her with kindness and respect, even if she never remembered it.
Janette was eventually diagnosed with vasovagal syncope, a wastebasket diagnosis given to those in whom all other known causes of syncope are ruled out. When I heard that Janette was getting ready to be discharged, I visited her one last time to wish her well. To my surprise, her son was in the room, helping her gather her belongings before taking her away. Before I could say anything, Janette began waving to me. Her son noticed the wave, turned to me and said, “Oh, you’re the amazing student who has been watching over my mom every day. She speaks very highly of you, and I really appreciate how much time and effort you’ve put into caring for her.”
I didn’t know how, but Janette had been telling her son the entire time about how I had been treating her. To this day, I don’t know if she spoke to him about me every day before her memory of our interactions faded, or if she actually did retain bits and pieces of our interactions that she recounted to her son later. What I do know, however, is had I acted on my thoughts of mistreating this woman because of my own impatience and stress, I would have impacted her in an entirely different way. And even worse, she may have even remembered it.