Friday, February 22, 2013

What I Wish I Had Done

I wish I had held his hand more.

One week from finishing my third year of medical school, I just had my first patient die.  

Mr. Wallace* had stage IV adenocarcinoma of the lung.  He was living independently, grocery shopping in his electric-powered wheelchair.  He had been on chemotherapy and radiation and he was all set for another round of palliative treatment when he came in to the hospital.

The last time I saw him, he kept talking about how his friend was about to visit, and he was futzing with his cell phone and saying that when she came, he was going to have her put her number in his phone under "family" instead of "friends" in his contacts list.  

I'm not quite sure why.  He didn't seem to have any family, at least not any that we had heard of during his nearly-three-week stay with us.  She was a good friend of his.  I am not quite sure why it was so important to him that she be listed as family in his cell phone, but it was something that he perseverated on often during that last week.  

"When she comes," he would say, chin tilted up so he could peer through the glasses perched at the tip of his nose at the small flip phone in his hand, "When she gets here, I'm going to have her put her number under family here in my phone, instead of under friends.  When she gets here, I want to have her change her number and put it under family instead of under friends."

He repeated himself over and over.  I would say okay, that sounds great, the first couple of times, and then try to ask one of the questions I needed to ask him - "Mr. Wallace, how is your pain?"  He would ignore me and keep mumbling and muttering, rarely looking up or acknowledging my question, although I knew he had heard me.  I would smile and nod for a few seconds and then try again, "Mr. Wallace, how is your stomach feeling this morning?  Have you had a bowel movement?"

Eventually he would look at me and answer my questions.  I would lean on the side rails of his bed, trying to get a little closer to him so that neither of us felt like I was shouting at him.  I tried not to push very much or very hard on his belly - I knew it was painful for him.  I knew it was riddled with metastatic cancer that was no longer being treated.  

I was off today when he died.

My intern updated me later on in the evening - we were both surprised.  "Didn't think he was that close," she said.  I was taken aback and immediately sad.  So strange, I thought.  Mr. Wallace, gone.  He was just here.  In fact, he had been in the hospital for my entire rotation there.  He was admitted on my first day on service, and he was the first patient I was assigned that day.  

I saw him every day.  But I didn't usually linger too long at his bedside.

He talked slowly.  He mumbled and he rambled and he repeated himself and he ignored questions and he would just keep talking and talking and talking and most days I would finally end up raising my voice just above his and say "Ok, Mr. Wallace!  We'll see you a little later, then, ok?  Bye, Mr. Wallace!" as I backed out of his room.  

I wish I had been more patient with him when he kept talking and talking and talking, repeating the same sentences and phrases and questions over and over and over again.  I had other patients to see.  Other patients that had a lot of the same issues.  Elderly, hard of hearing, terminal illnesses, chronic pain, intractable nausea, hard-to-manage constipation.  

We had a very busy service.  It was a terrible call schedule.  Our team was an extra-special black cloud.  I was carrying five patients - the most, by far, that I had on any other service, all year.  We had morning rounds and noon lectures and student rounds and team rounds and notes to write and people to call and presentations to give and we had all the usual medicine clerkship lectures and exams plus a ton of extra end-of-third-year exams and random things that the school of medicine so conveniently decided to clump all together right in the last two weeks of the year, coinciding perfectly with a multitude of other deadlines.  

I was exhausted, burnt out, feeling physically terrible and emotionally brittle.  Little sleep, long hours, rare days off, constant demands.  Stretched way too thin.

But if I am very honest with myself, if I really, really think about why I didn't take more time with Mr. Wallace, or with a lot of my patients like him, it was because I felt helpless.  I felt totally impotent to help him, completely powerless faced with his problems.  He had originally been admitted for a pneumonia, but then it was one thing, after another, after another.  We had a terrible time fixing his constipation, then his diarrhea, then his constipation again.  We could not seem to get his pain under good control.  His nausea was refractory to everything we could think of.  His pneumonia cleared right up and he did not look better.  He did not get stronger again.  He did not get out of bed again.  His breathing improved only marginally.  We were only providing what amounted to palliative care, and we weren't being all that successful at it.  

I had such a hard time being with him because I knew that we were not making him better.  

A couple of hours after I learned that Mr. Wallace had died, in the middle of my ineffectual review for my exam tomorrow, I suddenly thought of him again and was overwhelmed.  As if the news had not actually sunk in when I heard it, but had just then fully absorbed and hit my bloodstream.  And I started to cry.  

I thought about the last time I went in to see him.  I thought about the first time I met him, and all the times in between.  I remembered how he had been asking for a shave.  I remembered his bald head, his hollowed-out cheeks, his jaundiced skin, the way he only sometimes wore his dentures, how obsessed he was with his cell phone.  And then I thought about how he won't be there tomorrow when I go in, and I cried.  I am still crying.

Maybe this is everyone's experience the first time their patient dies, I don't know.  But I also just thought about all the times I could have stayed with him longer, but didn't.  I thought about how I had stopped doing much of a physical exam on him when I went in to see him every morning.  I didn't want to exacerbate his pain any more than necessary.  But I wish I had.  I wish that I had touched him more.  I wish that I had held his hand more, just held it and stayed for a little bit longer.  Just listened to him for just a little bit longer.  He had to have been so lonely; I never saw any visitors in his room.  He had no family.  I am sure he probably talked so much from the moment our team would hit his door to the moment we left because he had no one else to talk to.  

I want to believe that we provided good care to him in the final days of his life.  I want to believe that I did a good job with him, that I was at least a little bit kind and comforting.  But all I feel right now is sadness, and regret that I did not do more.  Maybe it always feels this way.  Like I said, this is my first go-around.  I guess there is no way I could have known.  But I wish I had not left his room quite as soon as I did yesterday.

*Name changed to respect patient privacy and HIPAA law.

Thursday, February 21, 2013

Thoughts on a Thursday

This morning it was an immediately great day when I found the little iPod that I thought I'd lost.  Okay, well, actually, it was first an immediately crappy day when my alarm went off, because it went off at the time it has to go off these days, but then it turned great when I found my nano in the pocket of some pants that I haven't worn in a couple of weeks.  And then I spilled coffee all over the inside of my bag on my way to work (from my spill-proof mug, which is exactly why I have and use a spill-proof mug for my coffee every day, because I might do something like spill it all over the inside of my bag on my way to work... le sigh.)  

So, you know, plus/minus.  But overall good because I care way more that I didn't lose my iPod after all than I do about coffee stains all over a ton of papers.  (I think.  I will probably actually continue to be really annoyed by the coffee stains on my day planner for a long time.  And yes, I still use a paper day planner.  And I write everything in it.  And I sincerely believe that this is a habit I will not ever give up as long as I live.)

I don't know, guys... stress levels are at an all-time high, I have, OH, 5 EXAMS in the next 8 days, I am freezing cold in my house because we don't have the heat on (also WHY IS IT SO COLD IN ATLANTA??  this is NOT why I moved to the south!!!!), I have not blogged in forrrrever, I have not exercised in even longer, I want to eat everything in sight, I am probably PMSing, whatever, but anyway, tonight I decided to try this Brownie-in-a-Mug recipe from Pinterest.  The fact that I did this is probably sort of gross, but see above for all the reasons that made me consider it justifiable.

Here is the recipe with step-by-step pictorial in case you are also in the mood for something this disgusting/delicious:

1/4 c flour
1/4 c sugar
2 T cocoa
pinch salt

2 T olive oil
3 T water

Mix (use a sturdy spoon... just sayin').

 And because I am a total hedonist, I also added a few chocolate chips.

Microwave 1 min 40 seconds, top with ice cream.

It was...... you know what?  It doesn't matter.  It doesn't really matter that it was not exactly the greatest thing I've ever eaten in my life.  It was warm, chocolate, gooey, and, you know, had ice cream on it.  Which is pretty much all I want out of anything these days.

Thursday, February 7, 2013

Santa Catalina

This morning, during a pause on the wards, I picked up my phone to scroll through my Instagram feed.  And suddenly, in between food pictures and friends' babies and strangers' landscapes and other scenes mundane, humorous and beautiful, appeared this shot above.  

I almost squealed out loud.  Not only is this an amazing scene and an amazing capture (seriously, I dare you to tell me it didn't make you smile instantaneously), but I also recognized it right away, because I have been there!  You know the feeling when you are watching a movie and then all of a sudden there's a scene in your hometown or your college campus or the beach that you grew up spending every summer on?  It was that feeling, except maybe even cooler, because the picture was posted by National Geographic (natgeo if you want to follow them on Instagram- they have a great feed.)  I was so excited when I clicked on the link through the picture and confirmed that it was, in fact, taken at the Monasterio de Santa Catalina, in Arequipa, Peru. 

Right before I started medical school, I spent about a month in Peru by myself, living with a family, volunteering in a clinic, traveling, and brushing up on my Spanish in anticipation of finding demand for my language skills in medicine.  The entire trip was incredible... exciting, boring, intense, lonely, hard, and FUN, as any extended time away from home, in a foreign land and culture, especially if you are on your own, tends to be.  I blogged briefly about mi vida arequipeña on one of the several short-lived travel blogs I have kept at various points from around the world, but, as usually happens overseas, the internet was frustratingly slow and access was expensive, and I was too busy doing a lot of other things, so I had given up writing updates by this point in my month in Peru.

I finally visited the Monasterio during my last week in Arequipa.  It is on the city's must-see list, but between riding crazy local taxi-buses all over the city, hanging out at my volunteer sites and working on grammar and medical terminology with my tutor during the week, and traveling during the weekends, I hadn't found time to make it there.

So one morning I played hooky from clinic and caught a cab to the city center.

It was breathtakingly beautiful, and nearly empty, with just a handful of other tourists and a couple of locals exploring the extensive buildings and grounds.

I joined a small guided tour, and then, after it was over, wandered around by myself for hours, totally taken in by the beauty of the place, luxuriating in the perfect morning high-altitude sunlight, walking slowly, meandering down every tiny alleyway and up every winding path I could find, taking hundreds of pictures.  My surroundings drenched me.  The architecture, the colors, the textures, the stone- and wood-work, the combined Spanish and Andean influences, the cobblestones, the stark rise of volcanoes in the distance.  I let my imagination run with the history there, the furniture left in rooms, arranged as they were when daughters of wealthy families were sent to the convent with enormous dowries and their own servants to stay with them there for the rest of their lives as nuns (by tradition, the second sons and second daughters of every family were expected to devote their lives to the church... and the rich paid huge sums so that their daughters could live in convents like this one.)

Cloistered from Arequipa's congested streets, the monastery was peaceful and still inside its ancient white stone walls, a calm island in the very center of the frenetic city.  It was romantic, almost magical.

There was a very attractive man about my age wandering around Santa Catalina this particular morning, as well.  I had noticed him when I entered that morning- I had been right behind him in the short line to pay the entrance fee.  We each bought our passes and then I didn't see him again until later, after my tour was over.  We kept bumping into each other around corners and passing each other in narrow stone-lined corridors, each carrying our cameras and lost in our own worlds.  Finally, after about the sixth time crossing paths, we both paused, smiling, and leaned up against a rust-red wall next to each other, taking off sunglasses and introducing ourselves.

He was an Army ranger, enjoying paid vacation during his last weeks in the service before his contract was up and traveling his way through South America.  I was just days away from Air Force officer training and a move to Georgia to start medical school after that.

We sat in an enclosed, white-washed, sundrenched courtyard, sipping café con leche and passing the nuns' renowned homemade pastries and a piece of pie between us.  We shared stories from our respective travels and adventures in South America, told each other about our families and our backgrounds; we talked about our relationships with our siblings and reminisced about things from home that we were starting to miss; we talked politics and 30 Rock and The Daily Show.  We bantered about our favorite Peruvian dishes and discussed languages and education and religion.  

Hours passed.  The sun moved through the bright blue sky, burning through the thin atmosphere and turning our cheeks and noses pink.  Lunch in Peru was served in the early afternoon; the whole family went home for a big, delicious meal with no fewer than three courses every day.  Lucy would be worried if I didn't come home.  I was acutely torn between this surreal, exquisite experience... the setting, the perfect weather, the companionship, the conversation, the man... and my serious sense of guilt over worrying my protective Peruvian adoptive mother, who had taken such hospitable care of me in her home for a month.  With regret, I excused myself from our café-soaked reverie on the small patio and left the peaceful otherworldliness of the monastery to flag a taxi and head home.  

Travel romance is really the best, isn't it?  It doesn't even have to be a real romance, or last longer than a couple of hours.  I can still remember the exact feeling of that day- small, textured details jumping to life in my mind.  It was so immensely satisfying and so horribly unsatisfying at the same time.  I never saw him again, but thinking about that experience now still makes me smile.  It is one of my most vivid memories of Peru, and one I'm sure I'll have for the rest of my life.

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