“This is our sickest patient,” my co-intern began as she told me about one of her patients I would care for overnight. It was my first week of intern year, and I was assigned the overnight cross-cover shift for a busy cardiology service. Introducing myself as “Dr. Tredway” still rolled awkwardly off my tongue, but I had grown more comfortable throughout the week in my new role as a physician. I could field multiple pages about the forty-something patients I was responsible for each night. I proficiently prescribed bowel regimens and repleted electrolytes. I carried a code blue pager, but it had not chirped once.
“This is our sickest patient.” The daytime intern filled me in on the patient’s hospital course. Heart failure. Kidney failure. On multiple pressors. “We are titrating his dobutamine drip now. If he maxes out, and his MAPs are still below sixty …” she paused for a moment, recalling the contingency plan for this undesirable outcome, “… call the fellow.” As days-old doctors, starting our intern year on a complicated rotation, this was a common overnight instruction.
After I heard instructions for all of my patients, the daytime interns left and wished me good night. Their presence was replaced only minutes later by a grave looking nurse at my side. She informed me that, although our sickest patient was receiving the maximum amount of medication, he was not improving. We walked together to his room. An elderly man sat in the bed, arms awkwardly outstretched on the handrails. A BiPAP mask hugged his face, and he oscillated his head slowly back and forth as if it were a weight too heavy for his neck to support.
“Help. Help me!” he said as I took his outstretched hand. He squeezed my fingers lightly, and I reciprocated.
His nurse caressed his shoulder. “We are trying to help you,” she said. “What’s wrong?”
“Are you in pain?” she asked, and the patient continued his metronomic head shaking. “What’s wrong?”
“Help me,” he repeated, more softly this time, his jaw quivering. He looked to me.
“You’re in the hospital,” I reassured him, “And we are taking good care of you.”
I called the on-call cardiology fellow as soon as I left the room, and together we looked through the patient’s evening labs. His results showed a severe metabolic acidosis, for which his body was desperately trying to compensate with rapid breathing.
“He needs to be intubated,” I offered. I had embarrassingly stumbled through the fellow’s questions about what the cause of this patient’s acidosis could be, but I knew what would happen if he was not intubated. He would tire from his rapid breathing, he would become more acidotic, and, as much as I did not want to think it, he would die.
“He’s DNI,” the fellow responded. I thought about the implications of this. DNI — do not intubate. Without intubation, this patient would become sicker until his heart failed. I pictured the elderly man in the room, and envisioned his frail ribs cracking like uncooked spaghetti under my hands as I tried to pump his failing heart through his chest. And for what? I could keep his blood flowing, but in the end his heart would never beat by itself again.
“Is he DNR, too?” I ventured. The fellow informed me that, as of very recently, yes. I was thankful that I would not have to mutilate this man’s body in the last moments of his life, but my relief was short-lived. I had told this man that we were taking good care of him, but now we had exhausted all treatment options. My previous reassurances now felt like lies.
My patient was dying, and there was nothing I could do about it.
The nurse injected morphine through the patient’s IV, and his breathing slowed and deepened. We removed his BiPAP mask, and his head relaxed backwards onto his pillow. Even after hearing the nurse’s assurances that she had his comfort care under control, I was hesitant to leave the room. I knew I could do nothing more for this patient, but I struggled to accept that truth. I left to attend to other patients with a new disquiet squirming in my chest.
A couple of hours later, I performed my first death exam.
This is the first real dead person I’ve ever seen. The words came unbidden to my mind, and I startled at the realization, because it was not entirely true. Like every other medical student, I dissected a cadaver, and years before that I even peeked into my grandfather’s open casket at his visitation. What about this experience was different that I considered this person, and not the others, “real?”
I felt warmth still emanating from his body as I pressed on his nail beds and listened to his chest. I shined a light in his unresponsive eyes and looked down at his gaping mouth, unmoving, surrounded by stagnant air. He was not cold and rigid, not preserved in formaldehyde nor contracted in rigor mortis. He was warm and soft, as he had been in life, as I had seen him only moments before. My understanding of reality resided in the world of the living, a world reflected in his warm and supple body.
I wish I were a magician. I wish I could cure my patients, no matter their ailment. A myriad of reasons culminated in my desire to practice medicine, but, like most in this field, the dream of helping others encouraged me through my training. How could I reconcile that dream when I had proven to myself that, despite the “MD” at the end of my name, I was unable to cure this man?
Medical treatment has its limits, but empathy does not. A month later, I filled out another death certificate on another night of cross cover. I reflected to the upper-level resident that, despite not knowing either patient personally, this second death proved no easier on my emotions than the first.
“If it ever gets easier,” he immediately responded, “you’re doing something wrong.”
I am not a magician, nor will I ever be. Coping with the confines of medicine is tough, but I hope it never gets easier. When I told one of my first patients that we were taking good care of him, I had assumed that meant we were helping him stay alive. Instead, we offered him the most comfort we could in his last moments. Where medical treatment ends, empathy continues even more strongly in its place: no matter what, we can care for patients by simply caring about them.
Articolo di Caroline Tredway su KevinMD.com