Thank You

Marlena Wosiski-Kuhn

The interns were discussing which patients we should take. My two fellow students had ones that were deemed good learning cases but simple enough not to overwhelm a medical student on our first day on wards. "Mr. Williams is an interesting renal case" "But a lot of issues going on…" I didn’t want to seem daunted, "I can do it," I spoke up. And then I looked at the patients chart: hypertension, diabetes, heart failure, BPH, CVA, acute kidney injury, hypokalemia, anasarca and membranous nephrotic syndrome of unknown origin. So, a lot of issues going on. The renal biopsy suggested that the syndrome was secondary to something else and the chart showed that we had worked up every possible primary cause listed on up to date and beyond. The only options left were that it was actually an atypical presentation of the primary autoimmune type (send out lab still pending) or secondary to an unknown, unidentified malignancy. I went to see the patient.

The best way to describe Gordon Williams is a jolly old man. He always had a warm smile for me, always sparkling eyes, and whenever we finished our visits he would say "Thank you doctor!" He was willing to be our learning patient for faculty rounds and took every poke and prod with a smile and nod. He even tried to tell us jokes, and although usually we never quite got the punch line he would laugh regardless.

His condition continued to be a delicate balance of fluid and every day I worried more and more about the cancer that we couldn’t seem to find. I checked him over for strange moles, asked him all the strange questions I could find online, and obsessively checked for his PLAR-2 send out lab to result. On my tenth day, it finally showed up: PLAR-2 positive. It was autoimmune and could be easily treated with prednisone! When the renal fellow came in later that day I asked if I could go in with him to share the good news. Gordon smiled and nodded as we explained the treatment to him and as the fellows were leaving the room I grabbed his hand, "We finally know what’s the cause of all this and now we can start to fix it and get you back home to Billie Jo!" His eyes welled up with tears, "Thank you doctor!"

 A few days after that we discharged him from the hospital. He has been on our unit a total of 29 days, two weeks of which he was my patient. A few days before my rotation ended one of the interns pulled me aside and said that Gordon had been readmitted and was upstairs on the renal unit because he was now requiring dialysis, in case I wanted to go visit him. I went up there the next day – he remembered me well and the phlebotomist and I joked with him that if he missed us so much we would come see him, he didn’t have to come back to the hospital! We laughed and smiled but I could tell his condition wasn’t good. His IV sites were weeping fluid and he was as edematous as the first day we met. The next day I went back up to his room only to find it cleaned out. A nurse told me he had been transferred to a different unit, just like I was about to be too.

A week into my next rotation I got a page from one of the students I had been on general medicine with: "Mr. Williams is in the ICU. It doesn’t look good. I thought you would want to know." I looked up his chart and saw that just the day after I had last seen him he had decompensated quickly and was now intubated and on pressors in the ICU. It looked like he had a hospital-acquired pneumonia. I went to see him again and sat by his bedside hoping he could tell that I was there. The next day his family took him off of life support. 

 My very first patient was also my very first patient to die, and the immediate cause was an infection he got, technically speaking, from us. I knew that what we had done while he was in the hospital kept him alive but I worried that it had taken so long for the lab result to come back that we had missed our window of opportunity to treat him before he got ill with something else. There’s nothing I or any of the other doctors could have done to make that result come faster but, as another MD-PhD student I spoke to the case about it said, if I had that PLAR-2 antibody I could have run down to my lab, ran that western blot myself and had the result in 24 hours. Of course, that’s not a reasonable thought at this point but that’s part of what drives me to continue bench research. Right now, it’s not feasible for me to do something like that but, in my future, it is.

 


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Marlena Wosiski-KuhnYear of Medical/PA School: MD-PhD year 3 (MS3 + Graduate student year 1
W
here You Grew Up: Tulsa, OK
College Attended: Johns Hopkins
Favorite Quote:
 Be the person your dog thinks you are

Fun Fact: As a child I wanted to grow up to be a racer in the Iditarod


 

 

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