It was a busy day on the stroke service. Our entire team was getting slammed, admitting people with migraines, TIAs, and stroke-like symptoms. I already had three new patients that morning. And then the ED paged us again. A young 21-year-old guy who had just graduated from college was downstairs with the Worst Headache Of His Life.
Worst headache of your life = subarachnoid hemorrhage = not a good thing.
"You think you can handle this one, Michelle?" my senior resident asked me.
"Oh, I've already handled it," I sassed back. Because when I'm stressed out, I say inappropriate things to people of authority.
"What?"
"Nothing," I mumbled, as I ran down to the ED to meet the patient. And after getting a CT scan of his brain and a lumbar puncture, we ruled out hemorrhage, and started the work up for dissection.
He ended up having a pretty severe vertebral dissection. So we started him on some anticoagulation, but because Coumadin takes some time to reach therapeutic levels, he'd have to stay on our service for a couple of days.
[Day 2 of hospitalization]
I saw him the next morning for no more than five minutes, as I was just checking to make sure he was still alive and not having any more complications. I didn't have any extra time to spend on him, since I had patients with lateral medullary strokes and actual findings on physical exam that I'd have to report during my oral presentations. He was just getting anticoagulated. He was a low-priority patient to me.
I went home later that night, and upon checking my email, saw that my patient had found me on Facebook and sent me a friend request. I ignored it, but changed my privacy settings.
[Day 3 and 4 of hospitalization]
I had class on Friday, so I wasn't in the hospital. And Saturday was my designated day off.
[Day 5 of hospitalization]
I got to the hospital pretty early that day. I had to preround on my patients and my teammate's since it was his turn for a day off. I decided to check on my college grad first, since he probably had no complications and would be leaving as soon as his INR was therapeutic.
ME
Hey, good morning! I haven't seen you in a while! How've you been?
COLLEGE GRAD PATIENT
Well, I'd be better if you had friended me on facebook. Where have you been the past couple of days? Are you avoiding me?
ME
Uh, oh, um - I had class on Friday and yesterday was my day off. And uh, I'm not on facebook much, so uh, yeah.
COLLEGE GRAD PATIENT
I'm just teasing. It's okay if you don't want to be my friend.
ME
[nervous laughter]
Uh, let's talk about any overnight events. Anything happen?
Hey, good morning! I haven't seen you in a while! How've you been?
COLLEGE GRAD PATIENT
Well, I'd be better if you had friended me on facebook. Where have you been the past couple of days? Are you avoiding me?
ME
Uh, oh, um - I had class on Friday and yesterday was my day off. And uh, I'm not on facebook much, so uh, yeah.
COLLEGE GRAD PATIENT
I'm just teasing. It's okay if you don't want to be my friend.
ME
[nervous laughter]
Uh, let's talk about any overnight events. Anything happen?
We delved back into health-related conversation. No pain overnight, no headaches, no tingling, numbness, or weakness. I checked the computer. His INR was 2.1 - just therapeutic. He'd be going home that day, as soon as I prepped his discharge papers, I told him. He was excited - he had tickets for some concert that night.
The next day, we were back to our normal weekly rhythm. I was typing up discharge instructions for another patient when I got a page from my senior resident - "come to ED, now."
I ran.
Apparently our college grad was back. Thinking he had probably gone out drinking or done some massive headbanging at his concert, my senior resident and I were convinced he had done something to exacerbate his dissection. He had told the ER docs that he was having a headache, 10/10 on the pain scale.
Yet, when we pulled the curtain aside, he was lying there in his bed, in no acute distress. In fact, he greeted me with a cheery, "Hi Michelle!" when he saw me. As we probed further, we found out that he hadn't filled his prescriptions for his anticoagulation.
We left the room to check his labs.
"Damn irresponsible college teenagers!" my senior resident muttered, as he clicked around on the computer to see what our patient's INR currently was. But before I could jokingly remind my resident that college grads aren't necessarily teenagers anymore, we saw the number. His INR was 1.5.
He was subtherapeutic, and would have to be rehospitalized. "Dang it," I echoed.
"Hey, was it just me, or did he seem too excited to be back in the hospital?" my resident asked me.
"Huh? Uh, I dunno. Well, yeah, now that you've mentioned it, I guess so. I'd be pretty bummed out if I had to spend the night here," I replied.
My resident cocked an eyebrow at me. And then he wrote in an order along with bed assignment, male nursing preferred. I didn't even know that was possible.
His INR was back to therapeutic levels the next day, so we were ready to discharge him again. We personally filled his prescriptions and set up appointments for him. There would be no excuses for him to come back to the hospital.
Later that day, while I was finishing up some progress notes, I got a Facebook message. From my favorite patient. It was lengthy. And to be honest, it started off quite sweet, thanking me for taking care of him and explaining things in layman's terms. Then, he started telling me about how he was new to the area and wanted to get to know me better, when he wasn't stuck in a hospital bed. Perhaps I would agree to dinner and a movie?
I shrieked. And my fellow M3 teammate sitting next to me immediately looked over, read it, and started cracking up. "Well, now we know why he came back to the hospital." "Shut up." "Are you going to answer it?" "Hell, no." "You should! Be like, dude, I saw you naked. You'd think I'd say yes?" "Oooh, that's so mean." "But funny!"
I didn't answer it. He had been discharged, and I'd never see him again.
Or so I thought.
Two days later, while I was hiding in a conference room studying, I got a page from my resident - "Get ye to the library and stay there until I tell you it's safe to come back to the floor."
I was confused, but like a good medical student, I followed my orders and went to the library.
An hour or so later, my resident called me. Apparently, my favorite patient had been back to the floor voluntarily. He was asking the unit secretary to page me and my resident overheard.
RESIDENT
Hey buddy, why are you back? And why are you looking for Michelle?
PATIENT
Oh, I uh, think I left something here in my room, and I didn't want to bother you about it.
RESIDENT
Let me just send something really quickly on the computer, and then I can take you to your room and see if you forgot anything, okay?
Hey buddy, why are you back? And why are you looking for Michelle?
PATIENT
Oh, I uh, think I left something here in my room, and I didn't want to bother you about it.
RESIDENT
Let me just send something really quickly on the computer, and then I can take you to your room and see if you forgot anything, okay?
That's when my resident paged me with his 911 warning.
And that was my last day on neurology. And hopefully, the last time I'd ever have to hear about this patient. Because I honestly think I'd be okay never seeing or hearing about him again.
