Mr. B shook my hand as the paramedics got the stretcher ready to send him to a nursing home. His firm grip punctuated the end of a long hospitalization, which had been characterized by several decisions to leave the hospital against medical advice into extremely unsafe situations, leading into complex capacity evaluation decisions.
It was a pleasure to take care of you, I told him. He smirked back at me and replied, no it wasn’t. The truth lay somewhere between our two statements. Mr. B’s hospital stay had been something of a rollercoaster ride for me. The steep declines that represented my fear for Mr. B’s safety were interrupted by brief moments of connection and rapport. His transfer to a nursing home was in most ways a relief, as it would be a safe discharge plan, but compared to his previously nomadic lifestyle, the discharge plan seemed confining. The conflict resulted in a significant amount of consternation to a new intern.
My view on patient non-compliance shifted markedly in August of my fourth year of medical school. As a rotating third year medical student, I had some awareness that our white coats and large groups in academic medicine could be off-putting at best and that decades of our field’s past ethical transgressions fueled many people’s mistrust of doctors. Those classic student experiences impacted my frontal lobes. That sense of unease seared through my limbic system when I presented to my teaching hospital’s emergency room with a paralyzed hand.
A young lady with a paralyzed hand looked a lot like conversion disorder to the emergency room, as it was far from the classic presentation of Guillain-Barré syndrome, an autoimmune disorder that causes paralysis. Nothing about my case was symmetrical, until I woke up the next morning unable to move any of my extremities. I presented back to emergency room appropriately quadriplegic, and did a short stint on the general floor before rolling into the neurological ICU, complete with placement of tracheostomy and PEG tube.
As the heavy white doors closed to the ICU, I had a sudden desire to leave the hospital, and I thought about leaving against medical advice after waking up with an endotracheal tube in my throat. I wasn’t going anywhere. In acute rehabilitation, I would wave goodbye to the rehab attending as he got into his car and drove away from the hospital. Then I would get up out of my wheelchair and walk around, throwing my lightheadedness and fall precautions to the wind.
Several years and one excellent personal statement later, I am a resident in physical medicine and rehabilitation. I order restraints when they are indicated and I have placed orders for patients to be NPO, or have nothing by mouth. I have had to tell patients that they can’t feed their family members soup right now because of their difficulty swallowing. I have also had the joy of upgrading patients’ diets to something more palatable, and seeing people walk after traumatic injuries. Limiting patient’s independence still gives me pause, but I am starting to use the pause to think about why we are placing these limits and how to evaluate when they can be relaxed.
While Mr. B’s personality threw me for a loop as an intern, some of the impulses seemed familiar to me. I hope that he can have some safe fun someday.
Laura Black is a physical medicine and rehabilitation resident.
