My patient gave me this advice on the last morning before I left for Continuing Medical Education (CME):
“Learn everything you can. You are young. You still have lots of time.
“Always be kind. You were kind to me and when I saw you, I knew I could trust you. I knew I could tell you these things and that you would help me. Yes it’s important to be smart–so learn as much as you can… but it’s even more important to be kind. Because then your patients will confide in you. I don’t have much time left, but I wish when I was as young as you, that had always been kind, and been good to people. But now I want to pass these lessons on to my kids, I want to stop drinking and stop smoking and be a good influence for them. This is my advice.”
I missed a diagnosis of TB on a patient. She came in for other reasons, seemingly more concerning reasons at the time. Because there were other things that could’ve explained the weight loss–including severe depression, drinking a lot, smoking, not really caring much more, poverty, homelessness, not having a lot to eat. But there are signs that can tip us off. Like having a slight cough, but maybe it was from a smoker’s cough, especially if it improves. Weight loss is another sign that can trigger us to do a work up. Part of the work up includes an x-ray, because TB can show up as cavitary (big white hollow circles) lesions in patient’s lungs–which I haven’t seen since a lecture in medical school!
(This is a chest x-ray I used from a google search).
There are other signs of TB are clammy skin and feeling sweaty, which in an alcoholic patient can also be from alcohol withdrawal.
But after a couple days, it became suddenly clear that these symptoms, weight loss, night sweats, a cough…could be Tuberculosis! A delayed diagnosis may expose multiple nurses and behavioral health counselors to TB before getting a patient on negative pressure room with appropriate contact precautions. It seems so dumb to miss it, because I grew up with TB all around and saw loads of it in Peru and my international rotation in PNG. I even remember sitting in my 2nd year medical school class, calling out the answer when our professor asked about these symptoms. But I missed it, because it is easy to be distracted by everything else, and sometimes symptoms were explained by another “unifying diagnosis.” And now here, it makes me wonder how much I’ve missed. Since then I’ve learned just how prevalent it is here, and I will test probably everyone with even one symptom from now on! Or at least hopefully I will be much more astute.
It was a great learning case for me. And the best part is that sometimes patients stay longer for social reasons, for kindness, but it worked out for her medical condition to be properly diagnosed–sometimes patients stay longer and it lets us have time to do an inpatient workup for weight loss (instead of out patient). And then people can get treated properly and not spreading TB to others in the community.
The conversations with him reminded me of the poem, Kindness–I know I posted it before, but I hung it up by my computer, because it reminds me nearly every day to find a fresh well of kindness for everyone around me. And myself.
Before you know what kindness really is
you must lose things,
feel the future dissolve in a moment
like salt in a weakened broth.
What you held in your hand,
what you counted and carefully saved,
all this must go so you know
how desolate the landscape can be
between the regions of kindness.How you ride and ride
thinking the bus will never stop,
the passengers eating maize and chicken
will stare out the window forever.Before you learn the tender gravity of kindness,
you must travel where the Indian in a white poncho
lies dead by the side of the road.
You must see how this could be you,
how he too was someone
who journeyed through the night with plans
and the simple breath that kept him alive.Before you know kindness as the deepest thing inside,
you must know sorrow as the other deepest thing.
You must wake up with sorrow.
You must speak to it till your voice
catches the thread of all sorrows
and you see the size of the cloth.Then it is only kindness that makes sense anymore,
only kindness that ties your shoes
and sends you out into the day to mail letters and
only kindness that raises its head
from the crowd of the world to say
it is I you have been looking for,
and then goes with you every where
like a shadow or a friend.
Naomi Shihab Nye