Dramatic irony, part 1

This afternoon, I spent an hour interviewing a 70-year-old retired lawyer who had been brought to the hospital for "confusion" and "unpleasant vivid daydreams." When I first met him, he said to me, "Well, it's been a fascinating trip so far. I didn't know that all this stuff is going on, that delusions like this can happen to people." He then elegantly launched into a nonsensical explanation of recent events, from being lost in the snow in Vermont with only strange innkeepers in sight, to being kidnapped and brought to Japan, where he was given hospital socks. As I struggled to keep him on track and progress with the interview, I felt frustrated with his verboseness. Listening closely, trying to make sense of his eloquent speech, I realized that his words added up to nothing more than nightmarish delusions. He, too, has been struggling to make sense of these experiences: "I've been trying to analyze why these things are happening to me... I feel better since they've mapped out a game plan, [which is] to bombard people with reality." Later, he failed a simple neurocognitive assessment. A picture emerged of an intelligent, educated man using those reserves to compensate and mask a significant decline.

As the interview seemed to be going on forever, we paused for a neurology resident to do her exam. I watched as numerous Parkinsonian features were revealed: bradykinetic hand movements, perseveration, increased muscle tone, shuffling gait. After, I stepped out of the room to ask the resident her thoughts. "We're thinking Lewy body dementia," she said, a diagnosis that goes along with Parkinsonism. I felt excited at discovering something new, the chance to diagnose, glad to have stumbled upon a neuro exam for a disease I hadn't seen before. A hypothesis shared only between the resident and me, not yet voiced to the patient himself.

I stepped back into the room to finish my interview. Towards the very end, I asked the patient to describe his mood at present. "One hundred percent better!" he said, and smiled. "I actually think I have a chance now of being able to do things again, of going back to how I was. I was really worried about Alzheimer's, but the CT and MRI came back totally benign!" I choked up. Minutes later, I stood up, thanked him, shook his hand, and left the room.

Albany update

Just marched down Central Avenue in Albany with a mixed race crowd chanting for a more just and peaceful policing system. We started in Arbor Hill, the broke and black part of Albany where so many of our patients live. For a start, I felt safe in a neighborhood where I have been told never to feel safe. (That's been an effort of a local family doctor here, to get people out in the neighborhood and feeling safe.) People came out of their apartments to cheer, men joined in as we passed, cars stopped and honked in support. Just as I feel empowered by my white coat to join in where I might have been shy in the past, the rally seemed to empower this neighborhood; or perhaps the neighborhood, empowered, created the rally. I passed one patient's street and then another. I was so moved by the crowd chanting, marching with both hands raised, that for several blocks I was silent. But I am not a tourist: my grandmother drove black families to the polls to vote for JFK in 1960. As medical students, we work with people and care for patients whose communities face injustices and challenges that many of us don't face personally. I want to be able to look my patients in the eye and let them know that I know and I care about what's going on outside of the hospital. To demonstrate that people in a position of authority want change too. Last winter I attended my first rally ever, marching down Michigan Avenue in Chicago with Students for a National Health Plan, feeling awkward and ambivalent. Yet trying something once makes it so much easier to try it again, sets off a chain reaction.

My patient woke up

For the past three weeks, I have been following an elderly male patient. First in the ICU, where he was delirious, in and out of consciousness and often nonresponsive. I spoke to his daughter, who told me that before his 75-day-and-counting hospitalization, he had been an independent man who used to come to her house daily to walk and watch TV with her dog. She was concerned that with so many transfers between and within the hospital, his providers had lost sight of his baseline, and only knew him as the extremely ill, nonverbal, mildly disheveled patient before them. In fact he suffered quite a loss of independence and dignity.

Today I met him on the floor (out of the ICU, in a regular surgery ward), and I introduced myself. I often feel the need to be careful when revealing to a new patient just how much I know about them from reading the chart and speaking to others; I don't want to appear to be a stalker. In this case, the patient was lonely, and soon the encounter became intimate. He asked which daughter I'd talked to. We talked briefly about how long he'd been in the hospital. Without prompting, he burst out, "I feel depressed" and "I'm scared," a phrase he kept repeating. When asked why, if perhaps he is afraid that he won't get well, he said, "I don't know." I was scared knowing he was scared.