Coming in to meet the students, house staff, and patients for the first day on service always excites me. This Monday was no exception. What awaited me? How many patients would I need to see? What lessons could I impart?
When I arrived, we had 11 patients, two new, and nine had arrived previously. Going through the list, while routine, always stimulated questions and teaching opportunities. Sometimes the team had questions for me. Sometimes they had a mischievous sense of putting me on the spot. I always love that interplay.
When we got to the man in 558, they told a sad story of an angry man with terminal cancer. He had accepted this fate, but was angry that we could not control his pain. He was refusing opiates because the constipation pain was worse than his cancer pain. The entire team was avoiding seeing this man unless they absolutely had to because he would yell at them. Empathy becomes difficult when confronted with anger.
As we walked around the hospital, my mind never went to the man in 558. We had a variety of medically interesting problems. We had patients to examine and demonstrate physical findings. We had discharge planning.
But inevitably we got to 558. I went into the room to talk with him. The team had painted an accurate picture. He recounted the problem. He was obviously miserable. I told him that we would discuss a plan and involve palliative care. I explained that they were the experts at treating pain and side effects.
Outside the room, I did something I rarely have to do: I had the team discuss constipation management. Usually, I let the team figure this out without my interference, but in this situation, I needed to understand what had been done. As they recited their heroic attempts, I wondered how I could help.
I asked the team if they had tried an opiate antagonist. Having rarely used it, I could not remember the name. So we looked it up – methylnaltrexone. We ordered it and explained the situation to the patient. We hoped it would work. We still called palliative care.
The next day, the team reported that he felt much better and that the new medication had allowed them to restart his opiates. We go to enter the room, and a woman is sitting by his bedside playing the guitar. They are singing a song from Creedence Clearwater Revival. The music therapist is smiling, as is our patient. We learn that he had been a musician – a keyboard player – and that CCR was his favorite group.
The man in 558 became fascinating to everyone. He had great stories to tell. He become the musician rather than the man in 558.
He still had a terminal disease, but he had made his peace. We were able to make his days better.
Palliative care did a great job. Make each day the best it can be. And that went for the team also.
Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.
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