A personal story about a healthy doctor-patient relationship
One of my patients, an
old man in his late seventies, has been seeing me for his diabetes
control for a few years now. He never
missed his appointments, was always on time, always accompanied by
his son and had so much warmth. So much warmth that I felt like
addressing him as "thata", but I usually avoid adding any endearments
to any of my patients.
One day over a year ago (in early 2017), he asked me
if I would take a look at his wife. He said “Doctor, she has
multiple problems and has been seeing many doctors. She is mostly confined to
bed and very restless these days. Please see her". I said why not.
Next day, the lady
was brought to the hospital with a big bunch of old records.
Lady was indeed very
restless, screaming with pain. She said she had pain everywhere and was
not even allowing us to touch her. I looked at all her old records and could see that they have
been consulting multiple doctors for the last 4-5 years. In the last few weeks they were seeing chiropractors as well for pain control.
That was the start
of my journey with her.
Her primary complaint was pain everywhere, she was screaming with pain the minute I tied the BP apparatus. I did the initial assessment and told the family we need to admit her and evaluate her completely.
75 year old obese lady known case of diabetes, hypertension, hypothyroid, osteoarthritis of bilateral knee joints, peripheral neuropathy secondary to diabetes. She was on multiple medications for all her co-morbidities. She was also on antidepressants, pain killers and lot of other supplements.
I looked at all her medications and absolutely wondered what else can I do?
With great difficulty I managed to examine her. I felt she had irregular heart rate but all other vital parameters were normal. ECG revealed atrial fibrillation.
During atrial fibrillation, the heart's two upper chambers (the atria) beat chaotically and irregularly — out of coordination with the two lower chambers (the ventricles) of the heart. Atrial fibrillation symptoms often include heart palpitations, shortness of breath and weakness.
Atrial fibrillation can be acute or persistent one. She did not complain of any palpitations, chest pain, dizziness or any cardiac symptoms. Further cardiac evaluation her heart was functioning at 35%, she was in congestive cardiac failure. Patient was started on all supportive medications for cardiac condition.
Two days on, patient vital parameters remained stable, she continued to have atrial fibrillation but heart rate slightly lower. She continued to complain of severe pain despite being on all the pain medications. I explained to the patient's family in great detail how precarious and serious her condition is and assured them that we are doing our best to keep everything stable. The family had only one request, please do something for her pain.
I reviewed all her medications escalated her pain medicines, patient continued to be in pain, she did not seem to be confused or delirious, answered everything with utmost clarity.
All her blood investigations were within normal limits. I was at dead end at what was causing her pain.
Four days on, her condition did not change much. I felt I didn't have much to offer either. As I was just walking towards her room, the nurse who was looking after her the previous night, walked up to me and said, "Ma'am, last night patient spoke something irrelevant for few minutes, may be it was in her sleep, she said she was dead few days ago. I was terrified! She is fine now". That did sound creepy.
I spoke to the patient at length, and all she said was, I have unbearable pain and I just want to die. The entire family started to sob inconsolably. Her heart rate was much better although she continued to be in atrial fibrillation, her heart failure symptoms resolved. Clinically she looked quite stable but the entire environment of the patient's room was morbid and gloomy and I standing there felt responsible and helpless at the same time.
That one episode of irrelevant talk, could suggest delirium. I worked up for all possible causes of delirium, her electrolytes, liver and kidney functions, thyroid tests, sugars everything came back normal. She had done MRI brain few weeks ago and that was normal too. I even fancied, left atrium throwing some emboli (small blood clots) into brain circulation causing her confusion, but there was no way I could prove that.
I looked at all her medications again. She was on multiple antidepressants and I asked our psychiatrist to take a look at her. I told him we have no explanation for her pain and restlessness.
He spoke to the patient and family and came to the conclusion that it could be "Antidepressant induced maniac episode" or it could even be a "latent bipolar disorder". First one sounded more appropriate to me considering she didn't have maniac episodes earlier but again the only evidence for the illness is the very behaviour that it claims to explain.
As per his advice, anti depressants were stopped and we started on mood stabilizing agents. Over the next 3-4 days, patient improved significantly her complaints of pain reduced and looked cheerful for the first time. We mobilized her gradually, and was discharged after about 10 days of hospitalization.
She came back the following week, walking and looking lot better. I was delighted to see her smiling. Husband said, this is the best she has looked in years with tears welled up in his eyes. That was my silent joyful moment! That's what keeps me going, makes this profession worth it.
She continued to be in atrial fibrillation but at a stable heart rate and I started her on anticoagulation to prevent stroke. Over the next few months, she remained well but episodes of depression returned and drugs were adjusted accordingly. She was admitted a couple of times with hyponatremia (low sodium) and symptoms of heart failure. However, with progressive heart failure she was prone to develop arrythmias and sudden cardiac death.
Last week (in late Dec, 2017), she breathed her last at home with all her family members around her. The family members informed me and thanked me for all the support and for helping her live her last few months in a peaceful & active condition.
I was honoured to be treating the lady and to have known their wonderful family. Most adorable husband, who never left wife's side even for a minute and followed every single advice given. Son who accompanied the elderly parents always, never argued and completely trusted the doctors and the hospital. In current times of turbulent doctor-patient relationship, its reassuring to have these relationships.
Wishing my readers a very happy, healthy, glorious new year!! Let this year doctors and patients, take a new step in bringing the focus back on doctor-patient trust and relationship.
For those who are interested go through these links
switching-mood-depression-mania-antidepressants
antidepressant associated mood switching
Delirium in elderly