Continuity of Care

Interestingly, I had some continuity of care between my medicine and ICU patients. One patient I met my first day of medicine was a woman with diabetes and cirrhosis admitted for diabetic hyperosmolar non-ketotic coma. At the time, she had an abscess on her butt; surgery was consulted and they did a standard incision and drainage. While she was on my medicine service, we worked her up for altered mental status. As that cleared, she started to complain of more back and flank pain. Imaging showed blossoming fluid collections in multiple areas of her pelvis and abdomen. Again, we consulted surgery who drained it several times, but she did not get better. One morning, I went in to find the team afray because she had become hypotensive, tachycardic, and febrile. Unfortunately, she had developed necrotizing fasciitis, the dreaded "flesh eating disease." This infection of the soft tissues spreads rapidly and can kill patients within days. Immediately, surgery took her to the operating room for wound debridement. They opened her up and dissected away all the dead tissue. She went to the surgical intensive care unit. A week and a half later, I started my rotation in the ICU and of course, she was there. Since I knew her, she became my patient. Despite going to the operating room eight times in the span of a week, they could not adequately control her infection and they had to amputate her leg at the hip. On the surgical ICU service, I worked hard to control her pain and wean her off the ventilator. We successfully discharged her from the ICU to the floor. Unfortunately, she bounced back to the ICU a week later when more necrotizing infection was found in her back. She eventually needed a colostomy and a tracheostomy. On my last day of the rotation, I was able to discharge her again back to the floor. Hopefully this time, she is heading for recovery.

I also saw another patient on medicine in my first month and subsequently on surgical ICU. This patient is a paraplegic from a gunshot wound several years ago and had developed horrendous sacral decubitis ulcers. In order for the ulcers to heal, he needed a colostomy and ureteral diversion for plastic surgery to skin graft the wounds. When I was on the medicine rotation, we spent most of our time "optimizing" him for surgery, mostly by supplementing him with nutrition and getting him on a stable medication regimen. He was still on the medicine service when I moved to ICU. I forgot about him until weeks later when I heard that we had a paraplegic patient coming up from the operating room after a colostomy with ureteral implants. It was the same patient I had cared for on medicine.

I'm actually pleasantly surprised by these continuity of care experiences. It's wonderful and educational to see a patient's experience with a disease process and their hospital management. I felt that we were able to deliver better care to these patients because I knew them, I understood their entire hospital course, and I was able to treat them comprehensively as a whole person. After learning how different services operate and prioritize, I was able to incorporate a little bit of everything in caring for these patients.