Tuesday, June 18, 2019
Intern Year: Stories, Part One
I once told a patient that everything would be okay.
He died, suddenly and unexpectedly, less than an hour later in the pre-op area waiting to have his gallbladder removed.
It had been an easy and straightforward Emergency Department consult. He was a young male in his 30s coming in with cholecystitis, an inflamed gallbladder. My resident team and I had tackled it together in a coordinated, well-practiced dance – gathering history, consenting him, marking him, and explaining that the best treatment was to remove his gallbladder.
The patient had answered our questions in simple, short bursts, an underlying tone of hesitation and trepidation lining his words. I had started to pick up on it during the beginning of our interaction but as I started to explain what the surgery would entail in order to consent him, the fear in his eyes was hard to ignore. I remember that it stuck out to me in the moment that he was more fearful than most patients usually are.
After he signed the consent, I squeezed his shoulder. “Don’t worry,” I said. “It’s an odd day when we don’t remove someone’s gallbladder; it’s pretty common and we see it a lot. It’ll be okay.”
He was rolled to the pre-op area within twenty minutes of us seeing him. Not soon after, he seized, coded, and died.
The autopsy report was puzzling, the findings not consistent with what one would typically find in a young male. Other than that, it had been a freak occurrence that was out of our control. A haunting reminder of the reality that routineis a word that one should hesitate to – or never - use in the context of medicine.
I felt stunned when I heard the news, the look in his eyes and the words I had spoken to him replaying in my mind. It’ll be okay, it’ll be okay, it’ll be – oh no.
“We’re going to take good care of you,” is what I try to say now to patients. I think of this patient nearly every time the words tumble from my mouth.
Medicine can bring cruel, swift reminders that there are no guarantees in life.
I once had a patient who was watching Harry Potter.
She was also crying, softly rasping how she shouldn’t be alive.
The patient was a young female that developed necrotizing pancreatitis. The disease had wreaked havoc with most of her abdominal organs and wall, leaving a literal hole in her abdomen, exposing her organs to the outside world. She was a perfect example of the dilemma that can come from modern medicine – kept alive and functional due to extraordinary medical and surgical feats, but yet a gateway into the overall ethical discussion of quality of life and whether medicine in this day and age can do just as much harm as it can good.
I was on call one night when I received a page that her wound VAC – a device that essentially covered the hole in her abdominal wall – was malfunctioning, close to the midnight hour. I did my best to evaluate and troubleshoot it on my own, but I was still a fresh intern and the patient was in the tenuous portion of her hospital course. I texted my senior resident, uncertain of how to proceed. She came to look at it and after a few moments, she told me to stay in the room as she went to get a fresh set of supplies.
Like any good intern would do, I sat down in the chair next to the patient’s bed and waited.
Harry Potter and the Prisoner of Azkaban was playing on the TV, illuminating the dark room. Ron and Hermione were confronting Draco Malfoy at the outskirts of a snow-covered forest, unaware that Harry was nearby underneath his Cloak of Invisibility.
“I shouldn’t be alive,” my patient uttered with a quiet cry.
Harry Potter was throwing snowballs at Draco in retaliation for the insults that had been aimed at Hermione.
I had no idea what to say.
I had never been her primary caregiver – I didn’t know her like the primary day team did or the nurses that took care of her. I felt like an intruder, the MD behind my name without meaning in a situation that required a natural rapport built over time between two human beings rather than a fill-in provider and a patient.
Many don’t know that I almost chose Psychiatry as my career path; I have always felt a natural comfort with having difficult conversations in emotionally challenging situations, and I have never been one to shy away from digging deeper into the darker aspects of humanity in relation to medicine and mental wellbeing. But this was certainly pushing the boundaries of that comfort zone.
“It hurts so much, I’m in so much pain.”
Harry, still invisible, is messing with Draco and his two cronies, pulling the pants down on one and swinging the scarf around on the other, before tripping and dragging Draco a few feet.
The stark contrast of the moment – between Draco getting up and running away in comedic fashion punctured with intermittent cries from my patient about how she essentially wished she were dead – created an indescribable feeling of surreal disbelief and the sobering reminder that life can just simply be cruel, piercing through distractions and attempts at minimization without preamble, without cushion, and without decorum.
I attempted to offer some words of comfort in the moment, though I quickly realized the patient was in such a distraught state (understandably so) that it almost seemed like I wasn’t in the room. After a bit, I stopped speaking, figuring that sitting in silence was simply the best – and only - thing I could really do.
Harry Potter continued to play on and I could only hope it was succeeding in distracting the patient, though a part of me knew it was most likely just a background noise filler in what must be an overwhelming, terrifying reality in the grand scheme of the patient’s life. The scene moved on and at that point, I wasn’t really paying attention either.
In what felt like an interminable amount of time later, my senior returned and managed to fix the wound VAC. I lost track of what scene the movie was on when I left the room, moving on to tackle the rest of the chaos the call shift had to offer.
I haven’t forgotten the discomfort and the feeling of woeful inadequacy from that moment, but I also haven’t forgotten the realization that those moments are normal, and okay, to have.
We’re human, too, after all.
I once had a patient who cried about his breasts.
He was an older, transgender male with gallbladder cancer and a terrible prognosis. He had come to have a port placed so that he could begin chemotherapy. The patient and his girlfriend were kind in the pre-op area, offering smiles and warm introductions as I shook their hands.
When we brought him back to the OR and moved him over to the operating table, we worked to get him ready and secured as anesthesia worked from the head of the table. Towards the end of the preparation, we rolled down his gown as we normally would to examine the site – his chest – and get it ready to be sterilely prepped.
He started crying as soon as his gown was moved down. “I shouldn’t have these,” he sobbed, clearly overwhelmed, nodding down at his still-female breasts.
At that time, anesthesia started to sedate him. “Try and think of a happy place,” she said from the head of the table, the oxygen mask starting to come down around his face.
“I have no happy place!” the patient cried out.
I wonder now if the patient felt like he was devoid of hope. Perhaps having gallbladder cancer wasn’t the worst thing the patient had ever experienced.
I stood next to him as everyone worked silently after his admission (confession?). A few moments later, the patient was under (if he were to dream – what would it be about?)and we were able to start the procedure.
I have no understanding of what it feels like to be transgender in this world – to be born with a body that doesn’t match your gender identity….and then to experience all of the misplaced, horrid, inexcusable hatred that society has to offer.
“We’re about to roll he-she-it back to the OR,” I had heard out in the pre-op area. I’m still ashamed that I didn’t say anything then, a combination of letting my timidity as a beginning intern win out along with being shocked at the blatant rudeness and disregard for another human being.
The patient unfortunately passed away a months after the procedure. If the person that said those things were to find out about his death, would they wish they had said or thought anything differently?
Why is it necessary to say such things? Even if one has their personal viewpoints, why be hateful or spiteful, especially about someone they don’t know?
Why not still be kind and respectful, even when the person isn’t around or isn’t listening? Nobody’s perfect, we all make mistakes and sometimes fail at that concept - but that, in my mind, can be a true marker of integrity.
Maybe if people would spend more of their time and energy trying to genuinely connect with and understand another human being, then maybe my patient might have had a different response – maybe he would have had a happy place.
October 8, 2017: Shades (1-5) https://mylifeasafuturesurgeon.blogspot.com/2017/10/shades.html