The room was thick with darkness when I entered. I could see the outline of a large woman sleeping in a bariatric bed, and I dreaded waking her. My intern had prefaced my pre-rounds with skepticism. “You know, she’s a complicated patient,” words which filled me with hesitation and simultaneously sounded like a challenge. Those words saturated my expectations.
I decided to start with what I knew. I knew she was being treated for myelodysplastic syndrome (MDS) that had progressed to acute myeloid leukemia (AML). I knew she was status post left hemispheric stroke with residual Broca’s aphasia. My brief morning read of prior progress notes told me that she was in the midst of chemotherapy. Her blood counts were dropping fast, and her kidneys had seen better days. She had spiked a fever, and urine cultures had grown out 100K E. coli and Klebsiella, luckily pan-sensitive. Overall, she was a fragile patient with tachypnea at rest – someone who the resident labelled, “high crump potential.”
“Good morning. I’m working with the leukemia team this week. How are you feeling today?”
A bleary-eyed look; no response. I glanced briefly at sleeping family members, debating whether or not to wake them and ask how her night went. I decided to let them sleep for now.
She grunted and shook her head.
“Feeling like you can’t catch your breath? Trouble breathing?”
Another grunt and lateral head movement.
I went through a pertinent review of systems, and after a perfunctory physical exam which confirmed right sided paralysis, I left the room somewhat deflated, feeling like I should have picked an easier patient to start with, e.g. someone who could answer questions with something more than vague head movements.
I returned that afternoon to find her awake and alert. She spoke with hesitation and had trouble with word-finding and pronunciation. It took much patience on my part to understand her, but I did my best, partly out of duty to my patient, partly out of guilt for writing her off that morning as less functional than she was. I learned that she lived with her daughter and developmentally delayed sister, and that her daughter took care of both of them, even though she was only seventeen and still in high school.
Over the next few days, her course improved, and she warmed to me. I could make her smile or laugh. I learned the names of her sister and daughter who stayed every day and night in the room with her. I encouraged her to eat in spite of her lack of appetite and joked with her about my obsession over her bowel movements. Finally, on Friday, after 4 days with her on the service, I helped move her from the bed into a chair so that the physical therapist could work with her. Who knew such a small step would feel like such an accomplishment. She agreed eagerly when I offered to have the hospital speech therapist come by. We decided that the next day’s goal would be to get her in a wheelchair and push her out to the windows of the cancer center so she could see the rainstorm. “She loves watching the rain,” her daughter smiled.
On Saturday morning, I arrived to find rapid response in her room. She had spiked a fever overnight and had difficulty breathing, so the night team, thinking she was fluid overloaded, had given her Lasix. Her pressures bottomed out, and her kidney output dropped to essentially zero. She looked as ill as the day I met her. This was the first day I fully understood the disappointment of “one step forward; two steps back.” Given her fluid status and low blood counts, we gave saline boluses, pRBCs, and platelets. That afternoon, I sat down and talked with her. She confided that she was scared that morning when the rapid response people came. No one had explained anything to her; they were too busy fiddling with the machines and hanging fluids. But now, she felt better. We agreed that Saturday would be her day of rest, and Sunday, we would get her in a chair again. That evening, my intern texted me, “We moved your patient to the MICU. We will no longer be her primary care team.” Unsure of what that meant in terms of outcomes, I went to bed that night hoping for the best.
Sunday was my day off, so I slept in. As I lay in bed watching the gray day outside, I wondered if she had turned the tide in the MICU. I opened her chart, and the words hit with the weight of mountains: severe lactic acidosis, acute liver injury, acute kidney injury, ischemic bowels. Her code status had changed to DNR with a short note from the resident about the consultation with the family. A dull, heavy sense of resignation crept in on me. There was nothing more we could do for her. She was going to die. She was going to be the first patient to die on me.
I debated going into the hospital to see her before she passed. Finally, I packed my white coat and headed out the door. As I stepped into the family waiting room full of expectant faces, I could feel uncertainty and grief hanging in the air like a dense fog. Some are natural at comforting others. I have never considered myself one of those gifted people, but in that moment, the words slipped out effortlessly.
“I am so sorry.”
I stepped into her MICU room with her sister. As a medical student, I could see the signs: the loud thumping of the ventilator, her vacant expression, scleral icterus, rigid abdomen. As a human being, I could see that her suffering would end soon. I said my goodbyes and let her know that her family was here, and that they loved her. I hoped that she could hear me and understand. Her daughter was intermittently tearful, and her voice became cracked and strained as she spoke.
Her last words were, “Help me.”
As I left the hospital, the clouds broke and the pale, filtered sunlight scattered across the sidewalk. My patient never did get to see the rain.
Year in Medical School: MS3
College Attended: Harvard College
Favorite Quote: “It’s hard to remember that this day will never come again. That the time is now and the place is here and that there are no second chances at a single moment.”
- Jeanette Winterson
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