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403


“No acute issues overnight for 402.”
“403: this guy kept me up all night!”

I was writing feverishly as my resident was getting the sign-out from the night team. I wrote everything down, not knowing which piece of information would be useful. After sign-out the Green Team usually met on the second floor of the Smith building. I was running to keep up with my resident while trying to jam the patient list with all the information into my white coat pocket. My coat was already weighed down by a clipboard, the purple book of Pocket Medicine, pens, highlighters, band-aids (for me and my patients), granola bars (for me, exclusively), a reflex hammer and my stethoscope. This was my first medicine clerkship and I did not want to make a fool of myself.

During the team huddle, I was assigned to Room 403, Bed 1.
“There is a lot you can learn from this patient. You should see him.”

I got the one liner and was off.

“41 year-old-man with a history of IV drug use with a 2 cm vegetation on his aortic valve who came in with new onset headaches.”

403’s nurse looked unhappy after a busy night. She mentioned that 403’s wife was in the room, and that his son had apparently visited last night. I knocked on the door and went in. 403 immediately woke up. His wife was still asleep in the armchair next to him. I apologized and introduced myself. As my eyes adjusted to the dimly light room I saw a bald, cachectic man lying with his head propped up on multiple pillows.

After the requisite formalities, I asked how the night was. 403 hadn’t been able to sleep. He had an unrelenting headache that none of the medications were helping. I didn’t really know which physical exams to do to evaluate a headache, so I pressed on his sinuses, haphazardly checked his cranial nerves, clumsily flashed my phone light directly into his eye and did the routine heart, lung and abdominal exam.

403 had tattoos on his neck, his entire torso and two full sleeves. It was intricate, colorful artwork. A wolf was prominently displayed on his left arm and a tribute to his mom was tattooed on his left pec. I listened to the heart and lungs. As I did the abdominal exam I saw “Aryan Brotherhood” written in prominent lettering across his abdomen. My eyes quickly inspected all the remaining artwork and hidden in the mish-mash of memorabilia, Celtic crosses and skulls, were swastikas.

Aryan Brotherhood is a white prison gang. Rules indicated that you had to kill a black inmate to join. They preached the two-seed line theory of Christian Identity that whites were the “true Israelites” and Jews descended directly from the union between Eve and Satan. Their “Christian Identity” theology had inspired a man to fire a submachine gun in a Jewish community center and another to shoot and kill a black state trooper.

His wife was looking at me. I stopped and stood up straight, making eye contact with 403’s wife. My heart was racing: this was going to end poorly. My head was split between fear and anger. I was preparing the most scathing of rebukes when she asked how her husband was doing. I exhaled, said he was doing well, and left.

I had focused on the indignities my mother and sister suffered for being Muslim. I remembered the times I was told to “be careful” because of the color of my skin. I didn’t care about 403.

My presentation was a disaster. I didn’t know what the morning labs were or what the cardiology note had said. My resident noted that the morning CT showed multiple emboli to the head, which could be causing 403’s headaches. We continued with morning rounds.

Nobody asked if I wanted to be off this case, nor did I request to pick up a different patient. So, I woke 403 up the next few mornings, our interactions devoid of emotion. Each day he would have the same complaint — severe headache preventing him from sleeping. I wouldn’t inquire further, and would rush out of the room as soon as I was done.

Two days later his son was in the room when I arrived. 403 wore a huge smile as he played with his son on the bed. His wife had brought homemade soup for the nurses. The day after, 403’s son tugged on my stethoscope. He was incredulous that I could listen to a heart with that device. He forced a smile on my expressionless face.

On rounds later that day, 403’s pain issues were brought up. My attending did not want to feed 403’s habit by prescribing narcotics. We hadn’t changed his medication in the past few days and had convinced ourselves that 403 was faking the pain. As we were about to move on, I spoke:

“Can we start him on scheduled Tylenol or Tramadol? The current regimen is not managing his pain.”

“Sure,” my attending said, dismissively. And we moved on.

That was one of the first times I had suggested a change in the management of a patient. It was months before I realized what I had done, and I am still unsure why I did it. Why did my third-year medical student-self think that this was important? Why did I advocate for this patient?

Of course, I had multiple theories. I was doing my job; I was helping out the nurses; I did it for his family; I did it so I wouldn’t have to make up a physical exam for headaches every morning. Ultimately, I did it because he was a person in pain and I had the ability to help. Our shared humanity allowed me to empathize despite my efforts to distance myself. For a bumbling third-year, that was the biggest takeaway.

“My mercy takes precedence over my anger.”*


*hadith qudsi, a saying in which Allah speaks through the Prophet Muhammed PBUH.

Syed Shehab Syed Shehab (4 Posts)

Contributing Writer

Larner College of Medicine at the University of Vermont


Fourth-year medical student. Interested in issues around diversity and inclusion, social justice in medicine and looking at health systems and how they can be used to improve access and delivery of care.