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. When I saw her, she was on a break from her sedation, but still restrained. She followed me with her eyes. She had been breathing through a tube for about 72 hours. I was not very helpful, but I enjoyed seeing her and I think she enjoyed seeing me. The only therapy I offered was scratching. I was excellent at face scratching. I wondered how miserable it was to be restrained, ventilated, conscious and have an itch on your face. My own face started to itch. The patient communicated answers to questions by nodding her head in different directions.
“Do you have any pain?” Her head moved up and down, and then sideways…
“Are you having trouble breathing?” She looked at me blankly.
“Can I do anything for you?” I looked at her blankly.
I smiled, turned and started to leave. She grunted and I turned back around. She tried to communicate again with her bewildering head movements. I offered her my pen and notebook. With tremendous effort and restrained wrists, she wrote, “DONE SMOKING.”
I thought this was profound and showed my colleagues her enigmatic message. They did not seem too impressed; I guess you had to be there. But that message really puzzled me. So here was my patient — a mother, a daughter, a wife — literally incapacitated by her disease, crippled on a hospital bed with a tube in her throat. Confused, restrained and dying. When she managed to wake enough to think, I wondered what she thought about. I bet she replayed her tumble down the avalanche and asked herself, “How did I get here?” I imagine she comes to this conclusion: I did this to myself.
As the mental fog lifts, she scurries to grasp her surroundings, alone with a medical student in the room. This is her chance! She writes the thing she finds most urgent, most important to communicate. As to a priest at confession, she admits her guilt and confirms her resolve to fix her problem. “Done Smoking.” Admits her regret. Her shame. Her guilt. This was my fault, I am at least partly to blame for this. And we all stand in the room and kindly, righteously, nod and agree, “This was your fault.”
But something about her conclusion was unsettling. Something about the situation was unsettling.
It is not the duty of the healer to assign blame to patients and pretend to know why a series of events evolved the way they did. Our actions are products of infinite inputs. Our life situations are not simply a result of our will power. Our family, finances, education, friends, genes, race, gender, television, advertisements, beliefs, pastors, teachers, diet, coaches, health and personal choice all factor into a complicated quantum equation. I wonder if it isn’t this equation that determines our life choices? I wonder if we have much less control over the variables of this equation than we pretend? Thus the question of judgment — of fault — is irrelevant and unhelpful. As future physicians, I hope we do not reinforce this narrative and burden that our patients carry.
That being said, I am glad she is done smoking.
Contributing Writer Emeritus
University of Kansas Medical School
I am a 4th year medical student at the University of Kansas Medical School. I am planning on pursuing a residency in Psychiatry and then hopefully a fellowship in Child and Adolescent Psychiatry.