*beep* *beep* *beep*. The dreaded sound of my pager awakening me at 3am. I had a cold which made it difficult to get myself out of bed. My fatigue had progressed to a point that getting out of bed felt like it may very well be the last thing I do. The next day on rounds was uneventful, except for the fact that my attending enjoyed stairs. By the 5th flight of stairs I felt one of my legs give out on me, and I unsuccessfully fought gravity and quickly landed on my face. By this point I started to have the feeling that something might be wrong, however, in the spirit of being a resident, I fought on and finished a couple more days of work. By the end of the week, I started to notice that I was forgetting things more than usual. I was unable to remember my patient’s lab values, vital signs or past medical history on the top of my head like usual. I must have just been tired, residency is tough after all, I thought to myself. Each day the difficulty with steps became more and more apparent. By the 5th day of my symptoms I could barely do a flight of steps without feeling profound weakness in my knees and legs. For me, this was very unusual. I normally run 3-5 miles per week and bike over 40. I finally texted an attending that I trusted, Dr. C.
Dr. C is a physician with a British accent that is known to put you on the spot and ask you in-depth physiology and pathology questions or ask you to quote the latest article from the new England journal of Medicine. He can quote articles from the 1980s and tell you which page and edition the study for the treatment you are administering was released. The breadth of his knowledge in neurology and pathophysiology is what makes him an impressive internal medicine doctor.
Dr. C examined me and found “3 beats of clonus on the right, none on the left, hyperreflexia more pronounced on the right than left diffusely, and possible anisocoria. Possible RLE>LLE weakness”. For the non-medical people: I had hyperactive asymmetric reflexes and weakness. Dr. C recommended I be admitted to the hospital.
I walked down to the ED from my wards shift and took off my scrubs, got a wristband, and sat in an ED bed waiting for the next steps. My mind began to race and think about all the possible diagnoses. I didn’t have long to think before the ED physician came in and said those dreaded words “We think you need to be admitted to the hospital”. As a physician, when you hear that, you know that something is not right. They need more answers before they can safely discharge you home. “Based on your social security number, you will be admitted to the non-academic team and be admitted by a very pleasant nurse practitioner or PA as they admit at night.”
Having been involved in PPP since my 2nd year of medical school, I have learned that you should always, at the very least, ask for a physician. I had already texted my attending beforehand asking if it would be okay to be admitted on his team. “I’d like to be admitted to the academic team. I know this will be a bit awkward as my coresidents and friends will be taking care of me, but my attending has already said he is willing to admit me.” For the ER doctor this was an easy decision as he would not get any pushback on the admission.
I woke up the next morning to my co-intern asking me a slew of questions. At the end of it, I asked: “what is your differential diagnosis?” The senior resident replied what I had feared all along “We talked to Dr. C and the neurologist, we think this could be infectious or rheumatologic, but its also possible that this a motor neuron disease such as multiple sclerosis or ALS. Dr. C thinks this could be herpes encephalitis so we will get a MRI and lumbar puncture to rule out any infectious causes”. My mind had already run through the possibility, and unfortunately ALS was a feared diagnosis given my reflexes and weakness.
The next few days were filled with many tests: MRIs, CT scans, a LP, and multiple physicians who evaluated me and gave their input. Medical students and coresidents who I knew took my history and physical in the mornings and took care of me while admitted. I made the decision to sacrifice my privacy so that I could get the best care. I picked the academic service as I knew I would always be evaluated by physicians throughout my admission. Luckily for me, my care was physician-led. I was admitted by physicians, my neurologist was an excellent physician, my Infectious Disease team was a team of physicians, my EMG was performed by physicians, and my images were read by physicians. My DPC doctor made sure that I got the referrals and testing I need when I was discharged from the hospital. When I needed an outpatient neurologist, I was seen by a physician and intermittently by a nurse practitioner who was properly supervised.
Luckily for me, my EMG was negative for ALS. On the final day of admission my lumbar puncture became positive for HSV-1. I received a PICC line and was given 21 days of IV acyclovir. I have made nearly a full recovery, thankfully.
It’s easy from a biased perspective to sit here and say that things may have turned out differently or worse if I had not seen a physician when I was admitted. I honestly am not sure that is the case, but what I am sure of is that being on an academic team of residents and supervising physicians is incredibly safe. I also am thankful to the nurses who were incredibly kind, caring, and helpful in getting the things that were needed. If I am ever given the option between an academic team or a non-academic team, I personally would pick the academic team every time. From the infectious disease fellow who ordered my acyclovir, to the radiology resident and medical student who did my lumbar puncture, the co-resident who ordered my syphilis, HIV, and monkeypox tests, to the resident on neurology that week, I believe I received excellent care. If you’re a patient at my hospital, my supervising physician and I will be happy to take care of you on the academic service.