- Patient is a 45 year old female
- 4 years ago, she was diagnosed with Stage 4 Cervical Cancer that had already spread to her bladder and small intestine
- Since the cancer was diagnosed at stage 4, chemotherapy was no longer an option and palliative treatments were initiated
- These treatments, however, were very expensive for the patient so she chose to only undergo selective procedures
- A few months ago, the patient developed salmonella
- Most people are are able to get over this condition without complications by letting it run it's natural course. This patient, however, had to be placed on months of Penicillin antibiotic therapy to overcome the infection.
- After discontinuing the medication, the patient begin experiencing serve abdominal pain every time she ate anything. She was convinced she needed Penicillin for the rest of her life to stop these pains.
- At the beginning of the year, the cancer was causing the patient to passing large clots of blood in her urine
- This subsequently caused her hemoglobin to drop down to 4.5 (normal ranges for a female is 12-14).
- The patient was rushed to the hospital for a blood transfusion. However, despite needing 3 units of red blood cells, she only received 2.
- Now, the patient still complains of fatigue and the whole purpose of the blood transfusion seemed useless.
- The actual reason the patient came in to the clinic was because she had not been able to have a normal bowel movement for the past week.
- The patient states she has the urge to go, but she sits there for at least an hour and nothing comes out.
- She has tried a variety of different formulas, but they either cause her to have severe cramps or they do nothing
- To sum up this current problem, eating a normal diet + not being able to have a bowel movement = severe abdominal distention and discomfort
I tried my best to listen to everything happening and plan what I would do to help this patient. When I went to examine her, I found her abdomen was not suddenly growing from only her new onset of constipation, but also ascites. This physical exam finding added a new dimension to my growing list of concerns for this patient. In the end, the doctor recommended the patient try a fleet enema for relief of her chief complaint for this visit: constipation.
I think about this a week later and I am better able to reflect on the situation. In the moment, I was completely overwhelmed. I felt like I had to address every problem the patient had so that she could be more comfortable. That task I had set myself up for was way beyond the power we had in the small primary care office. Now I can look back and assess what we were actually able to do for her at that moment. Her past medical history is in the past, we could not change the course of what was happening. The patient's salmonella and blood transfusion were an additional 2 problems I had no control over. The only thing we could change in that moment was the patient's constipation, which we addressed.
I worry that when I go to internal medicine I will face a similar situation where I am overwhelmed by complex medical cases. Seeing difficult patients now (in a more controlled, less acute setting) is preparing me to focus on problems that can actually be changed. It is easy to get engulfed in a patient and their problems, but sometimes you have to take a step back to look at the current obstacle and only fix the things that will give them a better quality of life. While you wish you could, you cannot fix all the things you see wrong.
Every provider is going to have patients that makes their mind work in overtime. I have to remember that I am only human too and it takes time to learn how to appropriately address these situations. Learning and fixing problems are not processes that occur overnight. Reflexions, such as this, will only help me become a stronger PA ready to help those complex patients.
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