In summary, it was a wonderful experience for many reasons but primarily because I had a great preceptor. I may have previously mentioned, he is a one-man-geriatric-team who previously trained and worked for years as a GP. He does all the hospital geriatric medicine consults as well as see patients in his own clinic, so I had the opportunity to work alongside him and in both environments.
He was an excellent teacher, he was never impatient with me or colleagues or patients, and always provided good learning opportunities. I especially appreciated that he trusted me with his patients. He believed in my skills, and where they were lacking he helped me develop them. I saw many patients on my own and he always listened to my assessments and trusted my findings and judgement. Due to this, I felt I had the opportunity to thrive and become more confident.
Many of his long term patients said I was very lucky to have him as my supervisor and I do not disagree! His patients loved him as a doctor because he was always comprehensive, understanding, and willing to give as much time as needed.
Through this elective, I also had the opportunity to experience many ‘firsts’ in medicine. Here are a few I would like to share:
- My first unexpected death. I was sent to see a patient who we were asked to consult for query MI (heart attack). He also had leukemia (terminal, not being treated) and hyperviscosity syndrome. When I came in to see him, he was sweaty, complaining of hard-to-explain discomfort, and extremely restless. He kept changing positions from laying to sitting up in bed. He was a little breathless (oxygen saturations in the high 80s to low 90s) but alert and speaking in full sentences. With his history and symptoms, I immediately wondered if he had a pulmonary embolism (clot in the blood vessels of the lung) instead. On physical examination, my main finding was bilateral costovertebral angle tenderness (often a sign of kidney inflammation/infection) which could also explain why he was in such restless pain. After a few short minutes, he began to quiet down. He laid still in his bed and appeared quite comfortable. I asked him how he was feeling and he said he was feeling better. He think told me to come closer and said, “You know, I have leukemia. And I know, I’m going to die. But it’s okay, I’ve accepted it.” Right after he told me that, he began to have difficulties speaking, opening and closing his mouth but no words would come out. Then, within a span of 3-5 minutes, his blood pressure dropped, he became completely unresponsive, and his GCS (Glascow Come Scale – neurological scale that measures a person’s state of consciousness) went from 15 (max score) to 3 (lowest score possible). His pupils became dilated and asymmetrical. It was just myself and a nurse with him at the time and he was DNR (do not resuscitate). The nurse asked, “What would you like me to do?” I felt so utterly useless because there wasn’t much I could do. I suggested pushing fluids to hopefully get his blood pressure up and agreed when she asked if we should send for blood gases. On previous imaging, he had progressive, chronic subdural haemorrhages (bleeding under the skull, pressing onto the brain) and from his acute deterioration, he must’ve had a massive bleed or other cerebral event. I called my preceptor who arrived within a few minutes and agreed there was nothing more to be done. He died within the hour. The shock of having someone unexpectedly crash on me and feeling so powerless to help was a very new experience to me, and the patient passed away. I had to sit in silence and digest afterwards for at least 15 minutes before moving on with my next task. My preceptor was quite understanding. “You get used to it,” he said, “but it never gets easier.
- Haemoptysis. The coughing up of blood from your lower respiratory tract. A term I’ve read many times in books. A question I ask all patients with a cough, however, aside from some blood tinged sputum, I have never really seen. We were on call and asked to come see a lady who had a 2 week history of coughing up blood. She was also a First Nations woman and had a previous exposure to Tuberculosis (TB). In addition, she had Takayasu’s Arteritis – an inflammation of the large blood vessels that particularly affects the aorta and its major branches (to the brain, arms, etc). This vasculitis had affected her so much and she had had such extensive previous surgeries to her blood vessels that she now only had very limited blood flow to her brain. If anything were to happen and her heart didn’t pump blood effectively, it would affect oxygen delivery to her brain and she likely wouldn’t make it through without severe brain damage. A lot of interesting factors in this lady’s presentation. While getting a history from her, she started to develop a gurgle in her chest and started to cough, and cough and cough. She brought up bright red blood, even big blood clots. It was the first time I had ever seen true haemoptysis. Not a sight I will soon forget. Throughout her hospital stay, her cough and bleeding eventually settled down, her cultures never came back TB positive and she was eventually freed from isolation. She had a bronchoscopy (a scope to look down the lungs and take samples) which didn’t come back with any sinister findings, like cancer. Whatever caused the bleeding remained a mystery but she left hospital happy and symptom free and promised to return for follow up!
- Met a man in emergency who had a STEMI (heart attack with characteristic ECG changes) that completely resolved after thrombolysis treatment on ECG. Then it came back! Definitely had to quickly transfer him to the closest facility for PCI treatment!
- Encountered a pulsus paradoxus (abnormally large decrease (>10mmHg) in systolic blood pressure and pulse wave amplitude during inspiration). This lovely 90yo lady had presented with 2 weeks of increasing shortness of breath and 2 syncopal (fainting) episodes. The doctors who saw her thought she was having heart failure and was fluid overloaded so gave her diuretics and sent her for an ECHO (ultrasound of the heart). Over the course of the day, she became delirious and her ECHO came back with unexpected findings. She had a large pericardial effusion (blood in the sac space around the heart) which was causing a tamponade effect on her heart. Needless to say, once the effusion was drained, she immediately felt a million bucks better. Apparently, I probably won’t come across such a significant pulsus paradoxus again anytime soon in my career.
- Had a lovely patient who had come in with severe sepsis but also had an ongoing history (years) of hallucinations. They always occurred around the time he fell asleep. They were never threatening but he described them with such amusement and laughter that of course, I joined in. “Oh yes, I see animals all the time. Today, I had a baby goat on my pillow” and “I see birds fly around chandeliers when I look up at the empty ceiling” and “I’m always reaching for coffees and food that are not actually there” and “When I watch TV, I will see another TV screen beside mine playing something else.” Incidentally, he was also found to have liver cirrhosis, splenomegaly, and abnormal blood results (significant of a developing haematologic malignancy) so there was that interesting aspect of treatment and management as well.
- Had a 90yo lady with such severe aortic stenosis that she was no longer able to get out of the bed without being breathless. She didn’t want invasive intervention but what really stood out for me was her passion in life. She was an avid hunter, baseball player, and loved fly fishing.
- Did my first trochanteric bursitis local anaesthetic/steroid injection. Probably one of the most easiest procedures I’ll ever do in my career but it was exciting and provided immediate relief for the patient.
Those are just a few of my experiences on my Geriatric Medicine term, I’m sure I’ll remember other ones I’ll want to share! One of the things I enjoyed most about this elective was the complexity surrounding each elderly patient, very rarely are they simple cases. Patients had cardiovascular disease, lung disease, dementia, mobility limitations, falls, frailty, diabetes, incontinence, no social support, etc. Their medication list hadn’t been reviewed and they were on too many or not enough medications. Physical examinations had to be comprehensive – I often did a cardiovascular, respiratory, GI and neuro exam on every patient – and often found incidental but important findings! Some findings include: postural hypotension or gait disturbances that could’ve accounted for falls, heart murmurs not previously mentioned, enlarged liver/spleen, etc. Even though at times it can be overwhelming, it was very rewarding to tease out all the pertinent information and use it to create an all encompassing plan of management.
The best surprise of my elective? My preceptor telling me that he would be on vacation during my last (4th) week on elective and offering me a ‘self-guided learning week’ if I wanted it. The opportunity to go home and spend an extra week with family in Ottawa? I told him that it would be a cherished opportunity, as long as he felt I had worked hard enough and was functioning at a level to deserve it. Yep! And backed up by a good assessment and an agreement to be a reference for me. So happy!
Even though it cost me an additional $400 (I know, it’s ridiculous) to change my flight, it was worth it. My sister was also back in Ottawa from Vancouver, so we had a complete family and quality time together. I was very grateful for this extra time with family as I really don’t know when my next opportunity to visit Canada will be.
Thank you to my preceptor, the hospital staff, and the patients I met for making my geriatric medicine elective such a great learning experience!