I actually don’t remember his name; he wasn’t my patient. I just saw him during rounds every day during my internal medicine clerkship. He was in his late-80s, and he was very ill. He had a long history of COPD, most likely attributed to his even longer history of smoking. He had been admitted to our service for a severe respiratory infection a few days prior to me starting the rotation. This was my last rotation of my 3rd year, and I walked in thinking I had seen enough COPD patients to know exactly what to expect.
The first day I saw him he was angry and frustrated. He was alert and annoyed as the attending, three residents and three medical students filed into his room. All of us students stood there quietly, totally useless, staring at him like a zoo animal while the attending offered few words with little meaning behind them. Something along the lines of “we’re doing everything we can” or “you’re getting the best possible care.” He finished the encounter with “so, we’ll see what happens,” which I later learned was the attending’s default response when he didn’t have a definitive answer for his patients.
I don’t remember much else about this first encounter but I clearly recall the attending’s reaction when we left the room: “It’s his fault he’s this sick; he still is smoking every day. It’s his fault he requires so much oxygen and is having such a poor response to the infection. He is self-destructive and killing his lungs.” I have heard physicians and students say things to this effect so many times at this point, and it still makes me immensely uncomfortable every time. Usually, it’s a morbidly obese patient admitted for shortness of breath, or a drug addict admitted for withdrawal. Regardless, I instantly feel for the patient and just moments later I feel weak and ashamed for being affected by these patients and their stories. I feel a desire to protect and defend these patients. Of course, I am not brave enough (or reckless enough, maybe) to stand up to an attending physician and counter his thoughts and opinions as he blames these patients for their shortcomings.
Why do I feel differently from these physicians who can look past the vulnerability of these patients? Is it good or bad that I am affected by these patients and their tragedies? Does it make me weak or does it make me understanding and compassionate? And then I feel a whole new level of shame for even having these thoughts. Of course it’s okay to feel and connect with my patients! The thought of becoming jaded with or ambivalent towards my patients terrifies me even more than being considered an overly-emotional physician. Either way, at that moment, standing there listening to the attending pass judgment on the man’s choices, I was sympathetic toward his suffering. Whether or not his condition was self-inflicted, the patient was old, sick, alone, exhausted and giving up and I thought that deserved some compassion.
It was easy the first few days to see this patient. He was out of breath, pale and a little diaphoretic but otherwise “normal.” His irritability was his most observable symptom in those first few days. He was relatively nice and polite when I talked to him, but I could tell he was exhausted and discouraged, and it was causing him to be easily agitated. But as his condition worsened and his body deteriorated, his entire presentation changed. He was the first patient I had ever seen who sounded like he was literally drowning in his own respiratory secretions. The gurgling noise of someone fighting to breathe with every inhale and exhale was a scary noise that stayed with me long after leaving the patient’s room. It was enough to churn my stomach and make my heart race at the very real promise of eventual respiratory failure.
As the patient’s respiratory symptoms continued to progress and his health further deteriorated, one attending finished his week and the next attending began. The incoming attending demonstrated a softer approach, and I felt more at ease as he spoke about his patients. His words were kinder. He took more time and gathered more of the patient’s story. His words and actions were tender, and his compassion for the patient built a more intimate connection in one day than the other attending seemed to build in an entire week. He was older than the other attending and maybe a little wiser, or maybe just a little more empathetic. I found comfort in his approach as I could tell this patient was likely going to be transitioned to comfort measures as the next step in his plan of care.
As a medical student, I often find myself standing in the background while the attendings and residents talk to the patients during rounds. During pre-rounds, I try to demonstrate some confidence and authority with “my” patients and act sure in my role as their student physician. However, during rounds as the low person on the totem pole, I find myself often relying on body language to give any meaning to my presence in the room. I try to make eye contact and give a polite nod or encouraging smile. Sometimes it’s a little awkward, but those few motions are my attempt at giving myself purpose in order to feel less out of place.
On the last day I saw this patient, he was hooked up to BiPAP and was only capable of nodding and moving his hands because any form of talking or other activity required too much exertion, and he did not possess the stamina. Feeling embarrassed and impudent, I gave an awkward wave to the patient. He returned my gesture and my heart sank. He looked so vulnerable and exhausted raising his thin, bony fingers to reciprocate.
It was a pitiful sight, really, seeing a grown man like that. Seeing someone so ill he can’t walk or talk or use the bathroom but still have the mental capacity to know what others must see when looking at him. I felt like an intruder on a private and demeaning experience as this patient lost his dignity with each labored breath.
The vulnerability of grown men and women during illness is something I was unprepared for when starting medical school. I can’t help to think that so many of our patients must feel so naked and exposed as they lay in their beds in their various stages of sickness and health as we flow in and out of their rooms in our clean white coats, professional attire, brushed hair and make-up. How helpless this must make them feel. In recognizing these feelings of helplessness and weakness I too often feel defenseless, exposed and embarrassed.
The patient died sometime over the next few days. I’m not sure exactly how events unfolded as the medical students did not round with the team over the weekend, but on Monday when I asked the resident where this man was, he looked in the chart and saw he had been discharged, readmitted and eventually succumbed to his illness in the ED. I felt this was a tragic end to a tragic story. He did not die in his home or surrounded by family; he did not even die in the comfort of a private hospital room. He died between two curtains in the chaotic, overcrowded ED. When this information was shared with me I took a breath, prayed a silent prayer and returned to work with my team hoping that my little prayer was not the only moment through which this patient would be mourned and remembered.