I'm back on the Resident Medical Team, our inpatient adult medicine service. Inpatient medicine has its ups and downs. The best part is that I have a lot of autonomy. The worst part is that I have a lot of autonomy. :) Seriously, it's a steep learning curve. Even though I have an upper level resident and an attending available, 95% of the rest of the work and decision-making is all up to me. I haven't killed anyone yet, so I'll take that as a sign I'm doing something right.

My toughest patient the last several weeks has been a man who was "found down" lying on his face for over 12 hours before his family decided he wasn't just "sleeping." It turns out this guy has a case of locked-in Parkinson's disease, which we initially thought was a reaction to one of his psychiatric medicines. After some more history taking, we learned he has the real Parkinson's disease and not just a syndrome. For those who don't know, Parkinson's is a disease that affects a portion of the brain that helps control movement. The brain tries to send signals to the body to move, but there's a signal mix-up. The disease presents classically with tremors, shuffling walk, and rigidity. Unfortunately, this man was showing signs and symptoms of Parkinson's disease for over a year, but his family didn't recognize it. His case is complicated by the patient having Bipolar disorder with psychosis. Some of the medicines that treat his psychiatric disease actually worsen Parkinson's disease by blocking an important neurotransmitter. And the medicine we're using in the hospital to try to treat the Parkinson's disease can send patients into psychotic episodes!

After several weeks of experimenting with starting and stopping his medicines, our patient has not responded. He has minimal speech, and he will barely move. The scariest part is that we all know that his brain is alive and working inside, but he is unable to express himself due to the advanced Parkinson's disease. It's like he's truly locked inside. He does moan quite a bit, and sometimes he will answer Yes or No questions after much effort. The medicine we are using to try to treat his Parkinson's disease is usually only moderately effective, and it will sometimes delay the progression of the disease, but it can't stop it. In our patient's case, it is probably too late. Since he can't interact with the world, it makes it difficult for him to get nutrition. We've been trying to spoon feed for several weeks and supplement with highly nutritious "Boost" shakes. After doing some calculating, I found that he is only getting about half of his caloric needs. If we don't put in a feeding tube, he will eventually weaken and die.

I arranged another big family meeting last week, and his wife and children were all very adamant that he would NOT want a feeding tube. So we're going to keep feeding him by mouth as long as he has an interest. After several more weeks, it is likely that he will weaken significantly, and he might even qualify for Hospice. It's an incredibly sad situation, but I must admit that I am really impressed with the family for not pursuing aggressive life-support. They have done a lot of work in educating themselves about the long term prognosis, and they all agree about what his wishes would be. I just wish there was something else I could offer. Moral of the story: fill out advanced directives, or at least tell your loved ones what you want to happen should you become too ill to make your own decisions!