Game face

I got into an argument with another provider. I really disagreed with his care. I saw his patient, and she didn't know that her diabetes was ragingly out of control, that her kidneys were actively failing, that the fatigue and dyspnea she'd been having for the last few weeks were heart failure. It was all news to her.

If you've working in any service industry, you know that what goes on in front of clients is very, very different from what happens behind closed doors. That shouting match you had with your co-worker is described as a 'friendly debate.' The flagrant incompetence of your staff is described as, 'Oh, she's still getting things figured out.' When we're standing in front of the people we're serving, we are trying to convey a sense of competence, so that they can have confidence in the care they're receiving. And sometimes, it's tempting to use this colorful language with diagnosis and management. We simplify and generalize and minimize and suddenly, terminal cancer becomes 'a concerning finding' and overwhelming sepsis becomes 'a serious infection.' In an effort to portray confidence, we create a false narrative of the events unfolding.

So when I saw this patient and told her the rather unpleasant truth, that she had multiple major medical conditions all doing terribly, she was stunned. And when I talked to the other doctor, I did not have any nice things to say, because looking competent and being competent are not the same things. And if you're going to put on a game face, then you'd better have the game performance to back it up.

Privileged #7 - comfort

In medicine, we are allowed to be involved in people's lives in a way that few other professions are. And sometimes, that can hurt. I had a former patient who was a lovable and gregarious gentleman with many unhealthy habits, so it was no surprise to me when I got the notice that he'd been admitted to the hospital. I checked the hospital records, and his room was listed as in the ICU. That's not super unusual. Sometimes, the hospital fills up and it's the only available bed, but I had a bad feeling, and so I checked his chart. He'd had a cardiac arrest and was currently on a ventilator.

I don't always visit my patients, but when someone is actively dying, I make the effort. I wanted to see him, see if I could help, and maybe assuage some of the guilt I was feeling. So after clinic, I headed over to the hospital, but I had a couple errands to run. I stopped by the cleaners to pick up my shirts, and I grabbed a few groceries for dinner. By the time I arrived at the ICU, things were fairly quiet. I made my way to his room and noticed that the lights were off and the monitors off. Before I could go in, the ICU nurse stopped me. She was one of my favorite ICU RN's, from an older generation of nursing when the job was brutal but humanizing. We'd shared many a dark moment in the unit, and this would be one more. 

My patient had coded about 60 minutes ago and died. They had only just finished getting him cleaned up for family to visit with him, pulling off all the wires and tubes and needles and tags. She was just finishing up her charting, since she was the code nurse for the event. 

I was devastated. I had just missed him. If I hadn't run those errands, I would've been there, but I wasn't there and for the dumbest reason. I couldn't have changed the outcome, and I wasn't the ICU doctor anyway, but he was still my patient. I should have been there, and I wasn't, because I needed to pick up my shirts before the cleaners closed. 

While I was standing there thunderstruck, the nurse pointed to the door behind me. The family was gathered in there. I hadn't seen any of them because they were waiting until the nurses finished cleaning him up. "You should go in," she said. So I screwed up my nerve and walked in to find twenty people jammed into a space meant for ten. There were sons and daughters and grandchildren and siblings, and at the head of the conference table was my patient's wife. I walked up to her and started to apologize profusely, but she didn't let me finish. 

"Oh doctor, I'm so glad you're here. Thank you so much for coming. It would've meant so much to him that you came." She then introduced me to her children and her grandchildren. I had expected wailing and sobbing, but they all had such a bittersweet expression, like they understood that this was the end of a beautiful moment, like the ending credits of a movie. They shared stories of his life with me, the life that I had never seen, the one that didn't involve A1c's or blood pressures or cholesterol levels. They laughed and cried. 

"Do you want to see him?" she asked me. Yes, of course. She let me go, while the family returned to reminiscing of better times. I left the conference room and went back to his ICU room. I held his cold hand and said my goodbyes. The family let me have my time, and I felt almost greedy that I should be the first to say my farewells. 

I came to the hospital expecting to provide support and comfort, and instead, I was the one who was comforted by this family who adopted me for one brief moment. I understood then that I was not a stranger in his life. I had been a part, however small it may have been, and was welcomed into the intimacy of his life. Since then, I've had other patients die, and I've grieved with spouses. I have several patients who've lost spouses who were under my care. They still come to see me, a testament to their faith in me, and when I see them, we share a little memory and a moment, and I can't help but feel so lucky that I am welcomed into their lives, and so honored that I should receive such trust.