BY RANDY MINTZ-PRESANT | Dr. Laura Mariani arrives early one Saturday at the Philadelphia Veterans Affairs Medical Center hauling two bags of groceries. As she unpacks them, she explains a PVAMC “tradition.” On weekends, the attending physician brings breakfast for the residents and students. Then, they all meet before going together on rounds. It’s a small gesture, but one that illustrates the appreciation PVAMC has for its Penn Medicine trainees.
The medical discussion that accompanies the juice and muffins is more telling. It shows the significant role the trainees have in patient care at PVAMC, the wide range of serious health issues they treat, and why their experience there can be so valuable.
Mariani leads the discussion, but everyone contributes. Second-year-student Deddeh Ballah reports that despite numerous tests, they can’t find an explanation for a 66-year-old patient’s nearly 70-pound weight loss. Dr. Vikram Prasanna, a resident, suggests testing the now 93-pound man for HIV. Mariani agrees, but also recommends looking at his living situation for signs of abuse and checking for heroin use. Then they move on. Another patient, whom Mariani remembers from previous years as a “really nice guy,” has a history of cocaine abuse and is in for severe abdominal pain. She agrees that they should test for lymphoma. A 52-year-old man is ready to be released, but as Prasanna notes, “he loves being here.” He is homeless, so she will work with PVAMC social workers to find him shelter. Daniel Caroff, a third-year medical student, shares his joy over an 86-year-old man who came in unresponsive but is now eating and talking. A more seasoned doctor, who knows the patient, wryly notes that they are in “the window between sedation and agitation.” The meeting continues for about 45 minutes, covering a multitude of physical, social, and emotional issues. Then Mariani asks in an upbeat voice, “Should we go see some patients?”
As they enter the hallway, the real costs of war and poverty are evident. Patients in wheelchairs maneuver through the corridors. Many are missing limbs. One wears a “Vietnam Veteran” baseball cap. Another has a small American flag mounted on his chair. One, who is walking, has the telltale eyes that come from years of living on the street. It’s a look that a hospital gown and shower can’t hide.
Patients, doctors, and nurses stop in the hallway to talk and joke with each other. Mariani leans over a wheelchair and rubs a patient’s shoulders. She helps another with his oxygen tubes. All the while, the residents are observing and helping. The atmosphere feels almost informal, more dorm-like than institutional. Yet when they enter the patients’ rooms, the mood turns serious. Mariani introduces herself as “Laura,” explaining that she is the attending doctor, and that the trainees are her “team.” Together they examine patients, asking questions and responding to concerns about such basic functions as eating and breathing.
One man’s legs are so swollen that he says, “I got a 20-pound foot,” and doesn’t seem to be exaggerating. Mariani and her team put on gloves and carefully unwrap the layers of gauze covering his legs. They examine the many sores and talk to him about his past care at other hospitals. When they are done, he asks them to cover his legs until they can be wrapped again, explaining that the sores, if left uncovered, will attract flies—perhaps recalling an experience from his past. Mariani, a pretty woman less than half his age, thanks him as they leave. “Anytime, I love you,” he calls back. Afterward, the doctors, clearly upset that the condition has gone this far, head to the computers to see what they can learn about the man’s medical history. After scrolling through many years of treatment, they decide to call the previous, non-VA facilities where he received care to discuss his condition.
Crossing the Street By Randy Mintz-Presant
Photography by Candace diCarlo
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©2009 The Pennsylvania Gazette
Left to right: Attending physician Martin Heyworth and Penn medical students and residents Bhat Soneel, Sarah Hull, David Carrier, and Misha Rosenbach start on their rounds.