The Consult

The Consult

It was spring and I had just returned home from a long day at work, when the phone rang. It was my mother calling from Florida. My father had taken ill suddenly and had to be rushed to the hospital. He was in his eighty's and had been in poor health for a while. He had heart disease and Diabetes and had been undergoing treatment for diabetic foot ulcers.

I called my sister who lived close to them. She was in the hospital with him. She said it did not look good. Both his heart and kidneys were failing and he was being admitted to the intensive care unit. I immediately arranged for a flight to Florida the next day. My brother and other sister were also rushing there.

The next day all four siblings met at my father's bedside in the hospital. It had been several months since all the siblings had been together. The doctors told us that he had suffered another heart attack, and this time he had badly damaged his heart. His heart was failing and his kidneys were failing too. He continued to decline and having difficulty breathing. After three days in the intensive care unit, we as a family decided to make him primarily comfortable.

He was placed on morphine and moved to a regular room. He looked much more comfortable and we all took turns staying at his bedside. He was then moved to a hospice center. I was sitting next to my father in a darkened room. He looked quite comfortable, and I was reflecting back on his life, when suddenly I received a text message on my work phone. It was from one of our resident doctors back in North Carolina.

He had an interesting patient. It was a visitor from Africa, who had come down with Malaria. I was the only Infectious Disease physician in my hospital and thus the request for advice. I texted back my suggestions for treatment. Doing this actually helped me deal better with my father's illness. Early next morning my father passed away peacefully in his sleep. I and one of my sisters were at his bedside.

After this, we got busy with funeral arrangements and taking care of my mother. My colleagues at the hospital were very kind and send many condolences. One of the residents at the hospital even got a collection of money from the other residents and made a donation in my father's name to the Diabetes foundation. They also arranged for a tree to be planted in his name at a state forest. I was very touched by these gestures.

The day after the funeral, I thought about the Malaria patient again. I had the ability to do a 'teleconsult' using my phone and a tablet computer at the hospital via a secure connection. Medical residents and my physician assistant would examine the patient, then connect me online, so I could directly communicate with the patient.

I did do the consultation and speak to my patient. While he was from Africa, he was of Indian descent. He reminded me of my father, who spend decades in Africa but was also of Indian descent. In a strange way, taking care of him helped me deal with my Father's death. The patient was doing better and the malaria parasite had been cleared from his blood.

Our patient told me that he had come to our small town in North Carolina because apparently this was a manufacturing center of agricultural equipment for the type of large cotton farm he ran in Africa. He was subsequently discharged and went back to his hotel room in town.

A few days later, I was back at work. In the hospital we were consulted again on our Malaria patient. Back in his hotel he had developed abdominal pain with persistent nausea and vomiting and been readmitted. The scan of his abdomen showed a significantly enlarged gall bladder.

At our consultation, we determined that his gall bladder enlargement was a complication of his malaria. The malaria had been cleared, but he had developed this condition called “acalculous cholecystitis”. This is a very rare complication of malaria.

We asked our surgeon to remove the gall bladder, which he did. After the surgery, our surgeon told us that the gall bladder had been removed just in the nick of time as it was close to rupture. Our patient made a complete recovery and eventually went back to Africa.

This was a very rewarding experience for me. Watching this patient's complete recovery helped me heal from losing my father.

I hope this patient continues to do well and is successfully running his farm today.

                                                    

Anopheles mosquito carrier of Malaria

The Akan Man

The Akan Man

I was rounding in the hospital recently when one of our Physician Assistants approached me with an unusual request. She asked me to cosign a consent form for a toe amputation on a patient as he was unable to give the consent himself.  This was an unfortunate case and here is his story.

Several months ago, a man was brought to our Emergency Room. He had been left at a local clinic by two men with whom he worked with on a farm. Those men disappeared soon afterwards, and the clinic sent him to our hospital. The only history we were able to obtain was that this man had become confused and walked outside into a grass fire, developing burns on his feet. He was unable to speak and appeared not to understand what was said to him. He was in his late fifties.

The medical term for this was expressive and receptive aphasia. The Emergency Room made sure he was not under the influence of alcohol or drugs and a CAT scan of the head confirmed a diagnosis of multiple strokes. A recent stroke had affected his speech and ability to understand any spoken words.

He was subsequently admitted to the hospital for further treatment of his strokes and his burnt feet. He had a brief period of lucidity in which he was able to state that he was a farm worker originally from Ghana in West Africa, and his mother tongue was the Twi language. He had no family in the United States. He was unable to explain how he ended up working in the small farm in North Carolina.

I have grown up in the West African country of Nigeria, but I had never heard of the Twi language. I looked it up. It is a language of the Akan people of south and central Ghana. It is a dialect of the more well-known Ashanti language. It is spoken by 6 to 9 million people.

The hospital was able to get a translation service with a Twi speaker on the phone. Unfortunately, that was not very useful as he still could not speak any words and appeared not to understand what was said to him. He had no social security card or any legal papers. His foot had developed gangrene in some toes, and these toes needed to be amputated. However, we could not communicate with him to obtain consent for the surgery.

I was asked to see him for Infectious Disease consultation about the gangrene in his feet with possible infection. I was able to advise on antibiotics, but he still needed an amputation.

The hospital social workers contacted the embassy of Ghana who offered no help. Department of Homeland Security as well as the United States Immigration services were equally unhelpful. In the end, the Physician Assistant taking care of him in the hospital asked me to be one of the three physicians to co-sign the consent form on his behalf.

I signed the consent form along with two of his other physicians and finally on the 98th day of his stay in the hospital, his gangrenous toes were removed. He was able to walk around but was still unable to speak and does not appear to understand anything said to him, even through the Twi translator.

Our discharge planners worked tirelessly trying to get him to a nursing home. However, without any legal papers, those homes had not been willing to take him. They were however able to get him temporary medicaid and after 130 days in the hospital, he was finally moved to a nursing home. He was moved back to the hospital after 3 months when his status could not be confirmed. He lived on the third floor of the hospital for many more months until Immigration finally confirmed he was a legal permanent resident and he was finally moved back to a nursing home.

He is still very far away from his family and birth place. In his almost two years stay in the hospital, he has had no visitors, and does not appear to have any close friends.

I wonder how he must feel, unable to speak and also not understand anything said to him while in a place that is so far from his home.

It is however amazing to see the dedication and hard work from his team of doctors, podiatrists, nurses, physician assistants, social workers and others. They have taken great care of this man, selflessly and with tremendous dedication. This makes my faith in humanity stronger than ever before. I hope and pray that our patient is in a place that will provide him equal care and comfort.

Gye Nyame - a symbol of the Akan people of Ghana

Frank

Frank

Recently we were in the process of moving from one home to another. I was going through a file of old papers, when an envelope fell out and caught my eye. It was addressed to me in such neat handwriting that it appeared printed. It was dated May 1st, 1998. I saw the return address was a Nursing Home. The name on the address instantly took me back to a very memorable patient of mine. His name was Frank. This is his story.

I first met Frank in 1996, when I was a second-year resident in Internal Medicine. I was asked to start seeing a patient who was described as being difficult and had fired two other residents from taking care of him. I did not want to have the same result, so I thought I would try to find out why he was so unhappy with his care.

Frank was a thin and short man. He had a closely cropped hair cut and looked really neat and clean. He had been admitted with an exacerbation of emphysema which caused breathing difficulties. This was mostly from a long history of smoking. He had never married or had any children. His only brother had died several years ago. I asked him why he was so unhappy with his care.

His main concern was that he liked to follow a schedule in everything. His food should be at a particular time as should his medications and breathing treatments. He even was very concerned about being able to go to the bathroom at least once a day, and he had been constipated since being admitted to the hospital. In his opinion the previous physicians had not taken these concerns seriously.

All my life I have been around family that have obsessive compulsive traits, and I realized that Frank was probably somewhat obsessive compulsive and felt the need to have more control in his life. I talked to his nurses and got him on a more rigid schedule. I even put him on laxatives and his bowels became regulated.

He did not fire me. On the contrary when he was ready to be discharged, he became my clinic patient and started to follow me as an outpatient. We became great friends. He told me stories of his career as a fireman and even shared pictures of his younger days with me. I realized then that he did not have any close family or any real friends. This may have been partly due to his obsessive compulsive personality.

Unfortunately, his emphysema continued to progress and he could no longer live on his own. We spoke at length about this and decided that a Nursing Home may be the best option. He was naturally sad about this. I would also no longer be his doctor as the nursing homes have their own doctors. We said our good byes and he was emotional, as I was. I did not know if I would ever see him again.

It was Christmas 1997, and I was pondering on my list for sending out cards. For some reason I thought of Frank and I mailed him a card to his nursing home. I was later informed that he had moved to another nursing home and was not sure if he ever got that card.

Several months later I received a letter in the mail. It was from Frank. In that letter he mentioned being pleased on receiving my card, and also described (with his meticulous handwriting), of all the problems he had in the nursing homes. He was moved from one to the other all over Eastern North Carolina. He was finally at a place he liked. In that letter he said very nice things about me, and this touched me greatly.

I later looked up the address of his nursing home, and realized that his small town was coincidentally very close to the small town I was going to be starting a new job in.

Soon after I started my new job, I did go to visit him on a Saturday afternoon. It was a typical nursing home. Quiet, dark and with a musty smell. The nurse on duty was surprised that Frank had a visitor. She led me to his room, and there he was, in a wheelchair with an Oxygen canula attached to his nose.

He was surprised, and appeared very pleased. He hugged me and we sat and talked for a while. He told me that he was quite content at this current nursing home as things were done as he liked. I promised I would visit him again.

However, soon after my visit, Frank passed away. He died peacefully in his sleep. I have kept his letter all these years and hope and pray that he remains at peace.

Excerpts from Frank's letter