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Getting By on Sunday

John Ramos

“So I put the razor blade in my throat and talk real quiet, then I reach in and pull the razor blade out.  This guy hit my hand so I lost my grip and it went down, and then I tried to throw it up but I couldn’t.  Next day my stomach started hurting.”  The man is in his mid-thirties, leathery skin and shoulder length hair, lying supine six hours after an upper endoscopy. His story makes my throat, which is sore this morning, burn when I swallow.  It is Sunday morning, and he is the first patient I round on.  My preceptor told me he was ready for discharge.       
            The EMR “Encounters” section has about 25 documents, each one titled “Upper Endoscopy” or “GI Foreign Body Removal.”  Considering he’s received patient education from a variety of providers, I am curious what else I can tell him.  I notice his hands are calloused and peeling, like my father’s hands. 
            “Do you work in construction?”
            “Not anymore really.  I don’t have a gag reflex, so I can to do this trick with the razor blade.”
            “May I ask why you do that?”
            “For money.  Or I’ll do it for drinks.  Or whatever.  Friday night, I saw this guy at a bar, and he told his girlfriend she had to see it.  I don’t do it for free so I give him my price.  Then he hits my hand when I reach in to pull the razor blade out.”
            “When you’re discharged from the hospital, do you know where you’ll you go?”
            “I don’t know, I’m homeless.  There’s a home I’m supposed to go to, but it doesn’t work out there.  You know I was sober for 20 years.”
            “That’s impressive.  What were you doing during that time?”
            “Going to a lot of meetings, had a pretty good support system.  I’d like to go back to school, do something better with my life.”

I complete and sign his discharge orders, and round on my second patient.  She’s 70, with end stage renal failure, heart failure, hypertension, diabetes, and chronic pain.  She was admitted five days ago after missing her dialysis appointment, presenting with altered mental status and hypotension.  Two previous encounters in the past year document a similar admission.  She’s had three rounds of hemodialysis since day 1, and she will need more.  At this point, she isn’t sick enough for a hospital bed.  However, she is too weak to take care of herself alone, or without help.  “I’m not going to a nursing facility…”
            I clear my throat, it still hurts despite warm tea.  “Did my preceptor discuss that with you?”
            “Yeah, he came in here, a couple other people, too, and they say I can’t stay here anymore.  I want to go home; my husband can take care of me.  We talked about it last night.  You go tell them that!”  

Later, I round on my third patient.  He’s 55, with uncontrolled hypertension and chronic pancreatitis. He presented 30 hours ago with an acute exacerbation of pancreatitis after an alcohol binge with opiate consumption.  He is still NPO, and his last trial of clear fluids yesterday caused him to throw up.  He reports abdominal pain and nausea.  He asks, “There’s no pill that can cure pancreatitis?”
            “No, I’m afraid not.  The next steps are to start with a clear liquid diet, and then eventually regular foods.  We don’t want to overstimulate your pancreas and make you sick again.”
            “Well I need to leave today.  My wife isn’t ready to go home; she still needs dialysis, and you all say she’s ready to go home. What kind of sense does that make?” 
            I listen patiently. 
            “She can’t stay at home if I’m not there to take care of her.”
            “Have you talked to your wife about this?”
            “Yeah we talked last night.  She doesn’t want to go to a nursing home.  I promised her I wouldn’t put her in a nursing home.  You don’t know what goes on in there, people get abused in nursing homes.”
            “Do you think you’re ready to go home?  We’re concerned you’re going to end up back here again if we let you go today.”
            “Man, I can’t even eat without throwing up.  I’m not ready to go home, but she can’t go home if I’m not home.” 
            A couple of hours later, he signs paperwork to leave against medical advice. 

After I finish rounds and submit the progress notes and discharges to my preceptor, I open my mouth in front of a mirror and use my pen light to illuminate.  Looks like exudate on my uvula, and my throat looks raw.  I palpate my lymph nodes, a few anterior cervical nodes are firm.  I swallow some Tylenol, drink more tea, and start to feel better.  When I leave the hospital I go to the urgent care, sit in the waiting room for forty minutes, have a rapid strep done, and see the PA. 
            “You definitely have some exudate…”
            She palpates my cervical lymph nodes, they hurt when she presses.
            “And you have quite a chain.”
            She looks in my left ear, and then my right.
            “That’s the reddest ear I’ve seen all week!”
            I’m not sure how bad that is, after all it’s only Sunday.
            “It looks bad; do you feel any pain?” 
            “Only in my throat; I just want to know if I have strep. Maybe I shouldn’t be at the hospital.”
            “Well I’m very interested in seeing how your test comes back.”
            She comes back a minute later. 
            “The strep test was negative, which is really surprising.  We can culture it, or we can treat your ear infection with an antibiotic, if it’s hurting you.”
            “It doesn’t hurt, but I wouldn’t mind the amoxicillin.  Can I still go to clinic?”
            “That’s fine, unless you spike a fever.  Lucky you; you probably picked something up at the hospital.”
            I laugh.  “’Yeah, I’m getting a lot more than an education.”


John Ramos
Year of Medical/PA school:
2nd year PA
Where You Grew Up: Sacramento, California
College Attended: California State University, Sacramento
Favorite Quote: “The pursuit of happiness is never-ending; happiness lies in the pursuit.”- Saul D. Alinsky?
Fun Fact: I was a professional entertainer for 2.5 years. 



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Last Updated: 11-25-2015
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