Internal medicine advocate
What Is Internal Medicine?
Dr Lydia Seetoh, Dr Nihar Pandit
Despite being an Internist for over a decade, I struggle to answer the basic question about the quintessential nature of my work. Various societies describe an Internist as an astute diagnostician, problem solver, team leader, provider of integrated care and proficient patient advocate. In other words, offering a one-stop, near complete answer where other specialists wouldn’t venture. But this is not what is perceived …
I discuss a case which put my team in a catch 22 situation, bringing out the essence of our work.
On a weekend just before the shift change, an elderly male was wheeled from the Emergency Department (ED) for breathlessness for three days. He had history of diabetes, renal cell carcinoma (status post nephrectomy) and dialysis dependent renal failure for the last 4 years. Grudgingly he had succumbed to family wishes to proceed with dialysis after nephrectomy despite the change in lifestyle he had been forced to adapt.
A few weeks prior, he presented for haematuria and was diagnosed with recurrent RCC in the remaining kidney. At the clinic visit with his wife and daughter, only palliative radiotherapy was offered as surgery was high risk. He returned home making a resolution not to proceed with dialysis, he ‘wanted to die’. And so, he stopped dialysis for a week before presenting to ED!
In the ED, shortness of breath was attributed to fluid overload and acidosis. Treatment for instituted for severe hyperkalemia (Serum K 7.2mEq/Litre) and he was sent up to the general ward.
When my team saw him, there were a few departments; we thought he could have been admitted to.
Urology; current issue at hand emanating from a Urological problem.
Renal medicine for severe hyperkalaemia; the only definitive treatment being dialysis.
Palliative medicine as the patient had expressed his desire to be comfortable and not suffer from anymore. Moreover, there was a life threatening cancer.
As we talked to him, it appeared he was depressed after the diagnosis of the recurrent cancer, which had propelled him into the decision to stop dialysis.
But what struck me, ‘is depression confounding his decision making capacity?’
Herein the true art of general medicine was revealed, navigating the landscape and crossing the hurdles while there is a time bomb with hyperkalaemia ticking close by …
We discuss this gentleman’s progress from a medical, ethical and social view.