On Patients Teaching Caregivers
by Raghav Girijala, M1

Before seeing my first patient, Mr. Griffin, at St. Joseph’s, I was sitting in the nurse’s station, rapidly sifting through pages of my Introduction to Clinical Skills handbook in an attempt to pick out salient words. The nurse was with the patient at the time, helping him complete his medical advance directive documentation. Vaguely recalling that it regarded end-of-life decision making, I expected Mr. Griffin to be relatively uninterested in having a medical student interview him at the moment.

When the nurse came back, she informed me that I could go in to see Mr. Griffin. Entering the room, I immediately registered the familiar drone of a History Channel documentary playing loudly and saw my patient opposite the television, reclined in his bed. For someone who was in the hospital, he was energetic, and when I introduced myself as a medical student interested in interviewing him, he animatedly invited me over to his bedside. He explained that his hearing wasn’t what it used to be, but that he was more than happy to help me.

I asked him what brought him to the hospital today, which caused him to chuckle and clarify that he had been there for a few days. Mr. Griffin said he had been diagnosed with left-sided congestive heart failure a few years ago. This was just another monthly visit to have his fluid drained because his kidneys were failing. I was hard-pressed to stifle my look of surprise, given that he looked no more than fifty. In hindsight, though, my disbelief was juxtaposed with hues of sadness for his condition as well as excitement that I had the opportunity to see a unique case.

When we finished my prepared set of questions, we continued to talk at length about his upbringing in the local area, his die-hard love for Aggie football, his fancy for fried chicken (he says Layne’s is the best), his desire to travel, and his love for his family. Mr. Griffin and I ended up talking for over an hour, and I thanked for him for his time.

Looking back on our encounter, I find it amusing that I considered him my patient. At this stage of my education, it is likely that patients are helping me more than I can help them.

Interviewing Mr. Griffin was, to me, a representation of the limbo in which medical students exist. We know enough to understand portions of a patient’s illness, but not enough to provide any type of medical consultation. At the same time, we are inexperienced in that we have not yet had to lose a patient or deliver bad news. Yet, we are not so naïve as to believe that we can solve every medical problem that comes our way. However, I believe that it is specifically a medical student’s existence in this intermediary state that allows patients to open up to us.

This begs the question then, what happens when this phase of our education is over? When we are no longer a medical student, but a physician, will patients be as candid with us? Given that we will have clinical influence, rather than solely an ear to listen, will they trust us in the same manner? And equally important is that if they do, will we make time to reciprocate, in this age of ever-increasingly fast delivery of care? I am not entirely sure of the answers; however, I am positive that our dynamic with patients will change. The goal is for us to continue to discover ways to connect with patients as we grow.

The Green Line
by Krystha Cantu, M3

I understood that dark things lurked in corners
That the hospital ebbed and flowed with its own sighs of conscious vitality
We were one behemoth organism sailing through the muddied waters away from death
carrying as many as we could
Young and old sailors with calloused hands and tangled nets
The motions were often routine, habitual, machine-like

Then one day, as I numbingly charted in the 4 am computer desk of the ICU
I heard a beeping monitor slow and slow ... as if anchored by time
Not my patient ... but when I stared into the room window ... I caught the waveforms slide into a solid green line
A man forcibly hugged a thin, disheveled woman and pulled her away from the patient in the bed
Motionless

I remembered a short documentary I had watched some time ago
about the people in the Himalayas who are prematurely blinded by the sun
Cataracts blurring their realities into amorphous darkness in their early forties
Their leathered cognac-tinted faces squinted and their labored hands grasping aimlessly in front of them
A team of eager ophthalmologists would perform cataract surgeries by lamplight to restore their vision
The final scene played like an opera ... with the same faces clutching the young doctors in front of them out of astoundment
Tears of joy
They could see again

This presented a similar nostalgic tug
As I felt the green line restore the same vision that often dulls prematurely in tired medical students
To restore the ability to see the pain and fragility of life that becomes silently imperceptible in crowded teaching hospitals
I needed to remember
I needed to see again

that morning I sat in the parking garage lamenting the death in room 412 until the windows of my car fogged
and I wept

Camp Kesem 5K
by Hollie Burrus, M1

Editor’s Note: Health Hullabaloo is an annual event encouraging healthy living in the Bryan and College Station communities. This year it was held on Saturday, February 20th.

An exciting part of Health Hullabaloo is the 5K race that starts prior to the health fair. Each year, the Pediatric Interest Group and the Health Hullabaloo coordinators promote the race in order to raise money for Camp Kesem. Camp Kesem is a program that operates free summer camps for children who have a parent with cancer. The camp is primarily run by college student leaders who have a desire to help children with the stresses and emotions that come with seeing a parent go through cancer. With over 3 million children affected by a parent’s cancer, this program is becoming increasingly important and allows children to have fun with others who understand their situation. Here, children become more comfortable expressing their feelings and are ready to manage the changes that will come their way.  

The Pediatric Interest Group aims to collect over $1,000 for Camp Kesem each year. This year, we were able to meet our goal with the help of the medical students, medical school staff, and Bryan/College Station community. Camp Kesem sent a few of their volunteers from Texas A&M University to come and cheer on the racers. They were grateful that we did this for their organization and are looking forward to working with us in the future.

For more information about Camp Kesem: http://campkesem.org/about-kesem

🍌 BEST BANANA BREAD EVER! 🍞
Submitted by Rachelle Mai, M1

Ingredients:

1 egg
3 ripe bananas
1.5 cups flour
0.5 cup sugar
1 tsp baking soda
1 tsp salt
0.33 cup melted butter
0.25 cups chopped walnuts/pecans (optional)

Winning
by Jessica Wilson, M3

I once jumped off a 500 foot bridge with a parachute
Launched myself over a waterfall in my kayak
Climbed eight pitches of a rocky cliff in Greece.
Some might say I was adventurous
but really
I just loved a good challenge.

My parents always said they knew
I was going to be in charge of something someday;
it was their job to make sure it was legal.
As a child, I was remarkably determined
At times downright stubborn.
I dealt with obstacles in plain, unequivocal terms.
I liked to succeed and was willing to work hard to do so.
I wouldn’t let anything stand between me and my goals.
I always won.

Things are different now.

Although I am every bit as determined, if not more so,
the obstacles have become more complicated;
the outcomes hold far greater weight.

Dyspnea
by John Pippen, MD

I opened the door to the exam room just a crack to see what waited inside. I did not have many records to look at, as this new patient was scheduled urgently because of dyspnea. I noted that she had just been discharged from my hospital after a several day admission for complications of advanced breast cancer. One of the breast surgeons had seen her, performed a thoracentesis for a right malignant pleural effusion, and done a biopsy of a cancerous nodule on her chest wall. She was discharged and told to follow up with a breast medical oncologist. Turns out, she had been treated for breast cancer for 2 years at a well-known cancer center in another part of the state. Her treatment had included surgery, chemotherapy, and radiation. The cancer had promptly returned, and she was given multiple marginally effective drugs, followed by a clinical trial. She wanted to have her cancer care taken over by someone closer to her North Texas home.

With this discouraging background information, I entered the room fearing that I would not be able to help much. Making matters worse was her pathology report of the chest wall biopsy, which confirmed triple negative breast cancer. For the breast medical oncologist, metastatic triple negative disease presents a challenge that is often insurmountable, resulting in the demise of the patient in a short time. The differential diagnosis of dyspnea in a patient with advanced breast cancer encompasses everything from the cancer itself to infection, and even complications of prior treatment. Dyspnea is a miserable situation for the patient, as hunger to breathe represents one of the worst of medical maladies. With all of this information swirling around in my head, I gathered myself and stepped across the threshold into the room with Mrs. Jay.  

I opened the door expecting the worst and feared that I would find a cloud of false hope and limited insight into a difficult and fatal problem. As I started my first and only patient visit with Mrs. Jay, some glaring abnormalities became quickly apparent. While speaking, she paused after every few words, making it obvious that her dyspnea was severe. Metastatic breast cancer had spread across her chest wall. Parts of her chest wall skin was hard as a rock, a condition known as carcinoma en cuirasse. It is characterized by infiltrating hard plaques across the chest and abdominal wall, giving the sensation of breathing in a tight suit of armor. On Mrs. Jay, it was extensive, malevolent. Her breath sounds were diminished even more on the right, marking the rapid return of her malignant pleural effusion, only a few days after her thoracentesis. As I was working, the nurse who had taken Mrs. Jay’s vital signs handed me a note saying her blood pressure was 90 systolic. Mrs. Jay told us that her blood pressure had been low for a month and she could barely make it from her bedroom to the bathroom, and could only make it to the kitchen when her son was at home to help her. Through her halting speech, she was able to eloquently and accurately give her complicated history, including all the drugs she had been treated with.

I asked Mrs. Jay what she did for a living. She had been an environmental advocate and outdoor enthusiast before her cancer limited her to ten-foot shuffles around her house. Her work territory included several places in Texas that I had hiked and fished with my family when I was a kid. We reminisced about the beauty of Texas outdoors. She smiled between labored words. 

After my assessment, it was clear that she could not tolerate invasive treatments such as a pleural catheter to drain her effusion. CT imaging searching for pulmonary embolism was out of the question. With this in mind, I sat down to have 'the talk' with Mrs. Jay. I had more trepidation than usual. I had just met her, and had not had time to earn either her trust or confidence. I made it a point to sit next to her, talk slowly, pause for questions, and avoid medical jargon as we spoke about the benefits of home hospice. I was surprised by her reaction. 

Mrs. Jay said, "Doctor, I am so relieved. I was so afraid that you were going to ask me to take more chemotherapy, or go on some experimental drug. I do not want any more treatment. I just want my breathing to be better."

I stepped out into the hall to find my nurse in order to get the ball rolling for Mrs. Jay’s enrollment in home hospice. The arrangements did not take long. Hospice was going to see her as soon as she got home with morphine for pain and dyspnea.

I was just about to step into a room to see another new patient when my nurse stopped me. Mrs. Jay had said some things to her on the way out of the office: "I am so glad that the doctor talked to me about hospice. I was so afraid he was going to just push me toward another cancer treatment. I know that I am going to die of this cancer soon. And you know what, for the first time in several months, my breathing is actually better." 

I paused for a deep breath of my own, and stepped into the room with the next new patient. 

Identifying information in "On Patients Teaching Caregivers" and "Dypsnea" has been changed to protect the identity of the patients.

SPRING FORWARD with the newly installed 2016-2017 board of THE SYNAPSE!

THANK YOU

To our amazing faculty mentors: Barbara Gastel, Mary Elizabeth Herring, Gül Russell, & AJ Stramaski
A special thank you to Barbara Gastel for helping with final edits.
Faculty Editor: Karen Wakefield