There’s a room in the center of a long hallway that connects two of the busiest units of the hospital– the CCU and ICU step down. Most days you can see nurses, MDs and others making the mecca between these two points, stopping in front of the door to punch in numbers and enter. Inside is a steel fridge full of sandwiches, cooled lettuce, tomatoes and turkey ready to be distributed to hungry patients. Right across is our old, groaning coffee machine that’s been churning carafes far longer than any of us have been actually practicing medicine. Eager residents wait beside it, briefly exchanging lab values and treatment plans before extending their styrofoam cups to collect their hot, bitter reward. Then off they go, out of the reprieve of this tiny room and into the chaos of the hospital floors.
I visit this watering hole as often or infrequently as the others who find themselves in this urban hospital. The sounds of crunching graham crackers, small talk, and bubbling soda have grown silent. Instead I either stare out the window to catch a glimpse of a pale blue April sky or scan over all the stuff scattered about. There’s a large row of bottles behind our poor dying coffee machine. They’re filled to the top with brown, viscous liquid and secured tightly with striking blue caps. It’s tube feed for the patients who can no longer swallow. I see it often, snaking its way through clear narrow tubes into the noses of some I care for. It only strikes me now because it seems like the best way to describe the atmosphere at the moment– slow, thick and barely moving.
My first patient died today. I spent about 4 minutes silently crying in the bathroom, feeling sort of silly. I hadn’t even really known him–we talked about college basketball for a few nights–does that count? I remember walking into his room late one evening after a nurse told me his foot was cramping. After looking up some stretching techniques I had contorted his foot into various positions until he exclaimed that the cramping had stopped–I had felt pretty good about that. In the past few days there were so many more memories like this; random, pointless, intimate? What else could you call it. I had stood speechless there while he cried some mornings, not being able to answer his question as to why it was him that was dying.
I had written a pretty long article about the events of that day. They included the terminal extubation I performed (my first ever), talking to the patient’s family, and watching his heartbeat and breathing slow on the monitor while mine only quickened. There were quotes about death, the meaning of it all and that Scrubs episode when JD talked about never forgetting the patient’s you lose. It was all ready to be published but in the end I got rid of it all.
The day my first patient died there was another one upstairs. To be honest most doctor’s hadn’t given her much thought, not because they didn’t care but because she was getting better–fast. It was an incredible recovery. She had come to us homeless, in alcohol withdrawal and intubated because of a terrible pneumonia. She was clearly malnourished– thin and frail with big eyes that squinted hard trying to grasp the English that everyone was speaking. Originally, when she was sick, she had attracted the attention of many; but now as she was becoming stronger she was delegated a room further from watchful eyes. I’d see her every morning quickly before rounds because she no longer required the care her much sicker counterparts did.
All of this made me wonder, what should ultimately be driving me–trying to delay death or improve life?It’s so bitter to lose someone you’ve been caring for, like you haven’t done enough. There are many patients I’ve come across this year that just can’t be fixed– it’s been a frustrating experience. I’m talking about the ex-war veteran with terrible osteoarthritis and many co-morbidities; the noncompliant alcoholic who won’t stop drinking; or the end stage COPD patient whose wife is across the bed looking at you for an answer. What do I do when I can’t fix these problems. Have I failed as a physician?
Today I spent a longer time than I normally would talking to a CKD patient about to start dialysis. I asked him about his fears, expectations, and what he thought of it all. I wasn’t focused on stopping death, that was coming, but there were so many other ways to improve his life. Education about what was going on, what to eat, where to go, who would be there and reassurance. There’s another patient who wakes up everyday not remembering who I am or what she’s even doing there. I can’t fix that either–but there are other ways to help.
Intern year is humbling. It’s shown me my limits as a person and a doctor. But it’s also taught me that there’s always something that can be done, and even if it seems small and insignificant in the big picture it should be done. It’s how people spend the last few days of their life having conversations about basketball and getting their cramps fixed. Or how other sick people, about to embark on a difficult journey regain some control of their life by learning there are ways to be healthy beyond being attached to a machine.
Ultimately, I’ve realized that small things matter–they aren’t trivial. All patient’s get antibiotics, procedures and chest compressions when they have to; but when those fail I like to think that it’s the kind gestures, listening and quality of life care that stand out. Those things never fail. More importantly they reaffirm what people have defined physicians as all along, healers.
You don’t fail as a physician if you can’t stop death, you do if you stop healing. That’s the difference.