A Learning Curve

HYE GI SHIM

Speaker:
[TO AUDIENCE] The third year in medical school: uncomfortable is the new comfortable, they say. The first surgery you scrub in to, the first patient with a headache, or a chest pain, or a fever, the first abnormal E.K.G. thrown at you, the first progress note you write. You might even pull out a chest tube for the first time, or perform your first A.B.G. or [holding up her right index and middle fingers] digital rectal exam.
And you will remember your first patient who…dies.
[Pause]

See—I love working with elderly patients. When they are in the hospital, they are usually scared, and they are usually the sickest patients, and they make me want to be someone who can…help.
You see, I feel this way because of my own grandfather. He lived with us for a few years, but I was kind of mean to him. He could sometimes be—[suddenly angry and defensive] he ONCE went through all the letters that my boyfriend sent me. He had decided that I was getting old, and made it his newest obsession to marry me off. I was what, [scoffs] twenty? Then one day he came in to my room and declared that I should marry the boy who wrote me.
And that just did it for me. I was like, “Grandpa, you don’t know what you are talking about! Go back to your TV and leave me alone!” And I slammed the door on him.

And I went back to school. And while I was gone, he had an accident. He fell. And he never woke up from his surgery.
You know, I think I could’ve been a better granddaughter. And I try to make up for it by being nice to elderly patients who remind me of my grandparents.
But I digress. Back to my patient. Mr. O’Neill, a seventy-nine-year-old gentleman who came in for what was thought to be a stroke. He was subjected to an extensive workup, and, along the way, we found what looked like lung cancer, and also a massive clot in his heart, ready to dislodge at any moment and clog a vital blood vessel. It could kill him, instantaneously. Even my attending said he had never seen anything like this before.

But Mr. O’Neill didn’t complain about being short of breath or any pain.
His daughter, Carrie, told me:

Daughter:
He’s a proud man. He will never complain. He has never missed a day of work in his life. He will never admit if anything is hurting. Even when he gets a gout flare-up, he will just sit there and suffer and wait for it to go away!

Speaker:
Then, one morning, he needed a brain MRI.
(SPEAKER TURNS TO O’NEILL.)
Good morning, Mr. O’Neill. You’re up early!
O’Neill:
I couldn’t sleep.
Speaker:
[With concern] I saw Carrie yesterday.
O’Neill:
Yea. She was here when the doctor gave us the news.

Speaker:
Will your other children be here today?
O’Neill:
I think so.
Speaker:
Good. Let me know if there is anything I can help you with, okay?
O’Neill:
Okay. Thank you.
Speaker:
So, anything happened overnight? Any chest pain? Fevers or chills? [Places stethoscope on his chest]
O’Neill:
No.
Speaker:
[Looking concerned] I hear some crackles in your lungs. You are short of breath, aren’t you?
O’Neill:
I’m fine.
Speaker:
How is your strength? [Placing both of her index fingers in front of his face] Squeeze my fingers as hard as you can.
O’Neill:
[Grabs and squeezes her fingers] Better. I walked to the bathroom yesterday.
Speaker:
Fantastic! [Releasing her fingers] All right. You are doing well. [Gently touching his arm] Hang in there, okay? And you’re getting an MRI today?
O’Neill:
I guess so. How long does that take? You know, I’m…claustrophobic.
Speaker:
Well, you lie down in a tunnel for about half an hour, but we can give you a sedative, so you won’t remember a thing. You’ll be fine. [Winks]
O’Neill:
[Looking down] Okay.
[Pauses, then looking at her in the eyes] Will you be there?
Speaker:
[Startled] Oh, me? [Stammers] I—I’m not sure.
O’Neill:
Can you be there?
Speaker:
Um…let me check what else is going on today. I’ll be there if I can, okay?
O’Neill:
Thank you.
Speaker:
[TO AUDIENCE] Would I be there?? This tough old man didn’t shed a tear after he was told about the diagnosis of lung cancer—but my mere presence would be reassuring?
I told him I would be there if I could—but I didn’t go. I couldn’t. Something else came up that morning. In medicine, something else always comes up.

So I was surprised when Mr. O’Neill came up in the Morning Report a few weeks later. The Resident was presenting:

Resident:
[Fast, crisp, detached] Chest C.T. showed bronchogenic carcinoma invading the right inferior pulmonary vein with infiltration of contralateral mediastinal lymph nodes. Biopsy later confirmed non-small cell lung cancer. After the diagnosis was made, patient did not wish to pursue any further treatment and was discharged home with palliative care. Ten days later, patient was re-admitted for a fever of one-o-three and worsening shortness of breath. He did not want to be resuscitated in case of cardiac arrest, and expired in the I.C.U.
Any questions?

Speaker:
[TO AUDIENCE] My patient. Now a case from which students can learn, a number that would be added to the hospital’s mortality statistics. My patient. What transpired between us—a conversation, a physical exam, however brief or inconsequential—now slips into oblivion.
Unless I decide to remember him—
Mr. James O’Neill. My first patient who died.

—END—