Contributing Writer
Oklahoma School of Community Medicine
Medical student at University of Oklahoma School of Community Medicine in Tulsa, OK.
While I could list close to 100 lessons, I believe focusing on three of the most important ones would aid other future health professionals in managing and ultimately treating the chronic illnesses that will become even more prevalent in many of our future patients. As a disclaimer, I do not claim to be an expert on this topic, but these ideas spring from my own personal reflections.
The old woman with long silver hair sat in her wheelchair, feet propped slightly up, smiling toothless among her layers of wrinkles. She waited for me to speak, deferring her decades of matriarchy and adulthood to the stethoscope I wore so casually after just months of earnest experience. Indeed, it sat lightly on my neck today but heavily on my heart. A few more seconds passed, as I contemplated how exactly I wanted to discuss her test results and how exactly I would ask her to proceed.
The other day, while scouring my computer for a lost document, I stumbled upon a speech I had given for my medical school’s anatomy donor recognition ceremony. It was an event held every fall, right after anatomy, during which our school’s first-year students showed their appreciation to the friends and families whose loved ones donated their bodies to science so that we could better learn the anatomy of the body. It has been a couple years since, so I decided to take another look at it.
The counting of compressions permeated the air as we anxiously stood by hoping to see any sign of life. We were trying to save Adam, a young Israeli-Arab who was on our inpatient service due to complications after his hemicraniotomy. He was hospitalized for nearly four months and his vital signs never stabilized, despite our rigorous and numerous treatments.
The beginning of third year clerkships is an exciting time for medical students. The first step of my licensing exam was finally behind me and now I could focus on applying the knowledge into a clinical context. I had heard a lot of stories about the third year of medical school. Perhaps what stood out most were the reflections shared with me when people witnessed death for the first time. From full codes to hospice patients, something about death seemed to draw out the most intense emotions and thoughts that can change lives forever. Although I always try to do the best for my patients, I knew it was inevitable that I would come across death. I wondered what profound thoughts and reflections I would have when I experienced it for the first time. It wasn’t too long before I was called to do CPR in the emergency department and I found it did not play out as I expected.
They’re out of place in dirty Crocs and wrinkled sweatpants. More notably, she’s wiping tears from puffy cheeks. It’s a sharp contrast to the nurses, who are too casual. One makes a remark to the other about a tangled tube. They always get that way. The other chuckles.
My first rotation as a third-year medical student, I met a man who will forever influence the way I approach my patients. He had come to the hospital because of rectal bleeding and was ultimately diagnosed with colon cancer. As I got to know him, I learned that he had fought in two wars, started a successful business and was married for more than 50 years. And he was enormous, six-foot five-inches and 280 pounds, with a voice that reminded me of Lee Marshell — think Tony the Tiger and the guy who sang “You’re a Mean One, Mr. Grinch.”
A 45-year-old with no past medical history presented to the emergency department with altered mental status. He was found face down in his driveway with no memory of an inciting event, or of his ride to the hospital. In the emergency department, the patient revealed that for the past two months he has experienced headaches, dizziness and left-sided weakness. On a hospital admission two months prior the patient reported similar symptoms but left against medical advice before any meaningful diagnostic testing could be conducted.
One after the other, day after day it seems, I find myself in a room where the resident is breaking the news of terminal cancer to my patients and I feel an overwhelming sadness belied by numbness. It has only been a week and a half on internal medicine and we have already diagnosed three unsuspecting patients with cancer.
Although there is really never a right time to die or even witness death, it is important to acknowledge that death is a reality, and one to which all health care practitioners will be subjected at some point in time. For that reason, I raise the question: is there an appropriate time to lose a patient? From my perspective the answer is yes, and for good reason.
She had survived an avalanche and was now lying face down in the debris. Longstanding ischemic brain disease had triggered a seizure. The seizure stunned the heart causing a cardiomyopathy. The cardiomyopathy, unfortunately, exacerbated her chronic obstructive pulmonary disease (COPD). As her oxygen saturation dropped, she was intubated and mechanically ventilated. She was now agitated, restrained and delirious.
“You need to come in to the E.D. ASAP.” A new patient was admitted at 2 a.m. and requested for a crisis counselor. Back in 2009 when I was volunteering in New York City, unlike with cases of sexual assault, survivors of domestic violence had to specifically request for the presence of an advocate. This woman, I’ll call her Sadie, had already taken the first courageous step to seek help.
Contributing Writer
Yale School of Medicine
Tehreem Rehman is an MD/MPH candidate at Yale/Johns Hopkins. She is invested in addressing the impact of adversity and trauma on psychopathology, clinical and community interventions for violence, and the relationship between healthcare provider biases and health inequity. Tehreem blogs at www.tehreemrehman.wordpress.com and can be reached on Twitter @tehreem_rehman.
