Information Withheld

“452 passed,” the ICU nurse told me.

I couldn’t remember who she was. I looked for her name on the list among the several dozens of patients I was cross-covering.

“452 passed,” the attending said to me 60 seconds later.

I didn’t need to be told a third time to understand the subtext. Hurry up and do your job.

I think it was pneumonia.

“I’m so sorry,” I said to the family upon entering. They watched as I performed the ritual with stethoscope and flashlight that had become second nature to me. No breath sounds, no heart sounds, no pupil response to light.

“Can we take away the machines?” they pleaded, looking at the silent ventilator.

Of course, said the nurse as I walked out of the room to write the death note. I heard her comforting the family.

Yes, it was pneumonia.

The medical student on our team, brimming with empathy, came up to me. “How is the family?” she asked.

I knew what she meant. What was second nature to me was foreign to her. Her question was broad because any kind of information was valuable to her.

New to the wards, she was hungry for interaction with patients. She wanted insight on what it felt like to be in that room. She wanted to be in that room.

But I hadn’t eaten in twenty hours.

And I felt like an interchangeable cog who confirmed what everyone already knew about someone I couldn’t even remember and filled out paperwork while the rest of the staff got to do the medicine and the nursing and the doctoring.

God, that question was dumb.

I calculated my response. “Sad.”

The team laughed as my senior grabbed my elbow and dragged me towards the cafeteria. “Come on, let’s eat.”

I’ll tell her tomorrow about the tenderness with which the granddaughter–about my own age–slowly kissed her grandmother on the forehead as she held back sobs.

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Time of death

I really hoped she was dead.

It wasn’t personal. It was as far from personal as possible. I had never met the patient while she was alive.


Every four days, my team and I are on call at the hospital. For about 16 hours, we must make decisions about people we have never met. The people range from sick and stable (patients from other medical teams and new admissions), sick and unstable (rapid responses for acute changes in mental status or vital signs), dying (cardiopulmonary resuscitation and/or emergency intubation), and dead (pronouncements).

My last name and pager number were plastered on the oncology floor, which increased the odds that pages I received would be about the dying or dead.  The first one was.

“I need you to pronounce,” said the nurse when I called her back.


As a two-week-old intern with a largely theoretical knowledge base and minimal understanding of a new hospital’s electronic and interpersonal quirks, I appreciate algorithms. “If x, then y” gives me relatively secure footing to rest decision-making upon, mainly because the decisions are pre-determined.

There’s not much that’s more algorithmic than a pronouncement. If called for one, go into the patient’s room. If the family is there, say that you’re sorry for their loss. Then verify that the patient is dead. Shine a penlight into the eyes and note that the pupils are fixed and dilated. Place a stethoscope on the chest and note the lack of breathing and heart sounds. Place a finger on the carotid artery and note the lack of pulse. Look at the clock. Pronounce the patient dead at the given time. Repeat again to the family that you are sorry for their loss. Ask them (and remind them that you must do this for everyone) if they want to do an autopsy. Leave the room, document the encounter.


My co-intern and I had debated if we preferred the family present or absent during the process.

Absent, I said. I had no desire to walk into a stranger’s funeral as a stethoscope-wielding technician who offered stock condolences.

But my colleague had done several without the family present and described it as something I didn’t expect.

“It’s creepy,” he said. “It’s just you and… you know.” That stranger on the other end of a one-sided interaction. He had almost had to bring the nurse in the room with him for company.

I had laughed then.


“The family was here last night, but they’re not here right now,” the nurse told me as I approached.

After getting a brief history of the patient’s medical course from the nurse and the chart, I opened the door to her room.

The efforts of the palliative care team were obvious. The shades were drawn, and the room was quiet except for the sounds of a waterfall playing in the background. I closed the door behind me to keep out the florescent lighting and beeping monitors and chatting of the nurses.

But with the closing of the door, I also kept out the sounds of the living. The intern had been right.

I inwardly cursed him and every horror movie I had seen to date. I cursed my reptilian brain for its very strong impulse to back away from the bed. I cursed my irrational thoughts that maybe she wasn’t dead after all, and wouldn’t it be terrifying if she sat up while I was trying to find her pulseless carotid.

I really hoped she was dead.

I watched 120 seconds tick by on the clock. This woman’s time of death was being delayed because I was too stupidly scared to confirm it.

I was not going to call the nurse for company.

Finally, a combination of embarrassment and obligation kicked in. I was called for x, so I did y.

Then I left the room and did z. I wrote a note, making sure I used the word “dead” (required). I called the primary provider. I filled out the death certificate.

I called the patient’s family, and they sobbed into the phone. Physical presence or absence was irrelevant, I realized. I felt like a stethoscope-wielding technician who offered stock condolences.


I’m thankful for the algorithms so carefully outlined in my resident handbook. Their explicitness is exactly what a new intern needs. But pre-determination does not preclude meaning. Unwritten between steps are a grieving family’s pain, a messenger’s fear, and a stranger who I will never meet.

If x, then y. But damn if x isn’t really, really hard.

To my first pronounced patient: your time of death was five minutes earlier. I’m so sorry for the delay. It wasn’t in the algorithm.

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Witness borne

“I need you.” The resident looked at me.

It was a rare permutation of words for a third year medical student to hear. After glancing behind me to make sure she wasn’t addressing someone else, I waited for the rest of her request.

*                                                                              *                                                                                 *

We had just left the room of one of our patients. She had stomach pain. A complete workup had been unrevealing. The endoscopy showed uninflamed gastric mucosa, the barium swallow and CT scan showed no masses or strictures, the gastric emptying study showed regular movement of stomach contents, and blood tests indicated no infection.

With no tangible source for her pain, her illness had morphed from “acute” to “chronic.”  It had components that were “psychosomatic” rather than “organic.”  These labels were code for a change in game plan.  It was likely the start of a long battle against pain with elusive origins. But it would be fought in the outpatient setting and not the hospital.

We implicitly understood this.  However, to our 25-year-old patient, nothing really had changed. She was still in pain, and we had muted but not fixed it. How could she go home?

The resident had a reputation for being persuasive. Explaining the test results was the easy part. Explaining what to do next would take verbal finesse.

“Look,” she said, and the patient looked up from her iPhone. “You’re sitting in the dark in the middle of the day. This can’t be good for you, right?”

She drew open the shades, letting the afternoon sun spill into the bed. The young woman didn’t blink.

“All I can think about is my pain,” she said.

“Of course,” said the resident. “There’s nothing else to do here but focus on it. When was the last time you got out of bed?”

“Yesterday,” said the patient. “Then I felt nauseous.”

“How about you try again today?” The resident kept her voice light, cheery.

“I’m going to get nauseous again.”

“That’s what the medications are for. They helped before, didn’t they?”


“Getting out of bed will also help the pain.”

The young woman slowly shook her head.

I watched the resident’s back slightly stiffen. “You don’t want to be in the hospital if you don’t need to be here. You could get sicker. It’s dangerous.”

“How can I go home if I’m in pain?”

How do you tell someone that more time spent with us won’t resolve her pain?

“Don’t you think you would feel better in your own home?”

The patient bit her lip and issued what to a hospitalist is the ultimate threat. “If you send me out, I’m going to come back.”

*                                                                              *                                                                                 *

In medicine we talk about “bearing witness” to the suffering of our patients. We treat with a pill or scalpel, and we also care by listening, by empathizing, and by giving patients our emotional energy.

But I’m learning that witnessing is a two-way mirror.

The slight creep of exasperation into the attending’s voice when the patient asks a question best answered by a social worker? The fidgeting by the medical student at the very back of the room during an intern’s long presentation?  How we listen to complaints, how we field questions, how we explain our plans, how we interact with staff?

How we try to explain to a young woman that she must leave the hospital without an answer?

Patients bear witness to our actions too.

*                                                                              *                                                                                 *

We left the room, and the resident let out a long breath and grit her teeth. There was another reason, she was convinced, the young woman was so reluctant to leave.

For all our talk of privacy, there is an elephant in each hospital room. Each patient is saddled with a roommate–a stranger who knows the intimate details of her medical story. The thin curtain between beds does nothing to block voices explaining test results and plans of care.

In this case, the stranger was another young woman with almost identical symptoms.  Ms. M was a new patient on our service, and she had listened intently to the entire conversation.

“Did you hear what Ms. M said to her family as we left?” the resident asked me, in a tone filled with righteous indignation. I shook my head.

“‘See, they’re kicking her out. Just like they want to do with me.’”

The resident puffed out her cheeks. “They’re feeding off each other. And now neither one is ever going to leave.”

She thought a moment. “I need you.”

My job was simple: Split the patients up. Ms. M needed a walk, and she needed it at a very specific time. I was to circle the hospital floors with her while the resident spoke to her roommate about leaving.

*                                                                              *                                                                                 *

I wasn’t a stranger to situations in which roommates witnessed the team’s reactions to each of them. In the past, the discomfort stemmed from the patients’ differences rather than their similarities.

The most jarring juxtaposition I remembered came with two previous patients, both middle-aged, on our medicine service months before.

When an otherwise healthy 45-year-old develops severe pneumonia with fluid buildup around the lungs, a doctor’s internal alarms go off. This type of pneumonia may signal something more sinister. It can accompany a compromised immune system, or a structural abnormality that makes it easier for an infection to enter, or with a mass that blocks part of the lung.

The woman and her husband were very quiet as we told them about the suspicious spots we saw on the CT scan of her lungs. When a biopsy confirmed lung cancer, they didn’t ask many questions and instead clasped each other’s hands as she cried.

They rarely moved or spoke much when we entered the room each morning. We told them the next steps for the day, and they would nod. Before leaving, the attending would pat her hand, which was surrounded by balled up tissues.

Probably because it was emotionally easier, each morning we stepped past her bed by the door and visited her roommate first.

The roommate was antsy to leave, but her slightly elevated potassium was taking its time to get back to a normal level.

“So what will it be, doctor-doctor?” she asked our attending, an MD-PhD. “More kayexelate today?” As a nurse manager, she wasn’t intimidated by the white coats who surrounded her bedside and seemed particularly amused by those of us wearing the shorter ones. With not much else to do other than wait for her electrolytes to rebalance, she bantered with the team.

Every time I laughed, I felt a flash of guilt about the woman an arm’s length away on the other side of the curtain. I’m sure I wasn’t the only one who wondered how she felt hearing our laughter.

Then I pictured her expressionless gaze as the attending told her about chemotherapy, about surgery, about what her new life could look like.

Maybe she didn’t hear it at all.

*                                                                              *                                                                                 *

“I’m getting tired,” said Ms. M as we slowly padded around the hospital floor. “Can I go back to bed?”

“Let’s sit down a minute,” I said, eyeing the closed door to her room and feeling like a bumbling accomplice in a B-movie.

One minute turned into several. I was stalling, but I was also curious. Who was this woman besides a hospital roommate, besides someone with intractable abdominal pain?

She worked as a nurse’s assistant. She was in danger of losing her job because she took so many sick days. She had a son. She was two years sober. She was scared.

Out of the corner of my eye, I saw the resident leave the room and flash me a thumbs-up.

As I helped Ms. M climb back into her bed, she grabbed my arm. “Thank you for listening,” she said, her dark brown eyes looking directly into my own.

I felt that familiar flash of guilt as I wondered whether she had noticed my own wandering gaze and attention.

*                                                                              *                                                                                 *

Walking with Ms. M hadn’t been the first time my gaze wandered. The first time was much worse.

The code stroke had been called during the last five minutes of my shift. Coat in hand, I followed the resident to the coronary care unit.

The 50-year-old man was answering questions strangely, a nurse said. He had seemed fine after his coronary bypass surgery, but now, several hours out, there was something off about his grammar and syntax.

The resident shined a penlight into his eyes. Pupils reactive, she reported with relief.

But his answers to her questions were fluent nonsense. Real words were arranged into an order devoid of meaning. He kept trying, unaware that he was a textbook example of Wernicke’s aphasia.

Then he projectile vomited blood.

Four of us grabbed his bed and ran out of the coronary care unit, through the hallways, down the elevator, and to a CT scanner.

One of his hands clutched his head while he grimaced in pain. The other hung on to the tray in front of him while he continued to vomit into it.

We stared at the screen as we waited for the image of his brain to appear.

It’s not often you hear four people gasp at the exact same time, but that’s what we did as we watched an enormous splotch of white appear that covered about half of the left hemisphere.

It’s strange to associate a color with a potential death sentence. On a head CT, white is blood. When it spills out of vessels or tissues, it irritates surrounding structures. One structure is the superior temporal gyrus, which when damaged renders a patient unable to speak coherently or understand others.

When there is enough blood, it increases the pressure inside the skull so much that structures in the brain become compressed. With nowhere else to go, they push against bone, which is perceived as immense pain.

The brainstem, at the bottom, bears the brunt. If the area postrema compresses, the patient feels nauseous and vomits. As the areas controlling heart rate, blood pressure, and arousal get damaged, the patient slowly loses consciousness and goes into shock. If the pressure isn’t brought down by medications or surgery, the patient will never wake up.

The man continued to moan in pain as we brought him back to the coronary care unit, pushed hydralazine, and paged neurosurgery. The resident shined a penlight into his eyes again. That his pupils now no longer contracted when light hit them was a surprise to no one.

Though I continued to understand none of what he was saying, he interspersed one word consistently among the rest: “hurts.”

He was confused, and his eyes were wide with fear. He looked at all of us, witnessing our own fear and concern. The second-year resident, somewhat pale, returned his gaze.

“This is … a little bit serious,” she said to him. I’ll never forget those words, her pause, the enormity of her understatement. They were the last words spoken directly to him.

As he slowly lost consciousness, he never stopped looking at us. I couldn’t stop thinking that my face could be one of the last he would see. I couldn’t stand that thought. And I couldn’t meet his gaze.

The anesthesiologists ran into the room for emergent intubation as he closed his eyes. I finally stepped back and stood against the wall, giving them space as they wheeled him away to the operating room.

It struck me how much courage it takes to tell a dying person he’s dying and continue to look him in the eye. This resident had only a few years more experience than I did. It struck me how much more I had to learn.

The resident turned away from the spot where his bed used to be, with tears in her eyes.

*                                                                              *                                                                                 *

The next morning I entered Ms. M’s room and approached her bed. The shades were open, and the bed on the other side of the curtain was empty.

With some apprehension, I roused her for the requisite line of questioning. I remembered her roommate’s resistance to answering questions and reluctance to look up from her phone.

“How do you feel?” I asked.

She thought a moment. “A little better, actually,” she told me, her eyes not leaving my own.

I’m not sure what she saw in my face. Maybe it was surprise that two women who were the same age, shared a hospital room, and presented with such similar symptoms could have different reactions. Maybe it was relief that I wouldn’t have to partake in any more roommate ruses. But I’d like to think it was happiness untinged by an ulterior motive.

She sat up. “Can we go for a walk again later?”


Note: Certain details of this story were altered to protect patient privacy.

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A Move to Scientific American

“Curious, have you considered joining a blogging network?” was how Brian Mossop, then Community Manager of PLOS ended his email to me over a year and a half ago.

I hadn’t.  It only took two phone conversations–one from Brian and one from then PLOS blogger David Kroll–for me to get excited about the possibility.  I already knew of PLOS and appreciated its open-access mission.  I was impressed by how quickly its new blogging network had attracted a close-knit and talented group of writers.  I couldn’t wait to join.

I’ve loved my time here.  I’ve loved the editorial freedom, the community, and especially the readers.  But after a year and a half, I’m moving again.  I recently joined Scientific American‘s blogging network, where I will be writing bimonthly posts.

I sincerely hope you follow me there.

I would also like to thank Community Manager Victoria Costello, for her work and support.  She asked me to add this to my farewell post, and it is truly an honor:

Shara Yurkiewicz’s insights into the human condition, filtered through the extreme circumstances faced by students going through the second and third years of medical training, uniquely inform the open access biomedical research that forms PLOS’ core publishing mission.  As I wrote recently in Ten Essential Qualities of Science Bloggers, “Shara shows the heart of a lioness…always with a healthy dose of self-deprecatory humor.” We’ll miss her narrative talents as much as her attention to scientific detail. And we wish her well at Scientific American Blogs.

– Victoria Costello, PLOS Blogs Manager

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Being Sorry

“You’re not sorry.”

Within two days two different patients said this to me, each with hatred in his voice.  Each time I was alone, each time I had known the patient for only a few minutes, and each time the rage was directed at me and only me.

For seven months, I had avoided being the bad guy.  When a patient got upset, he accused my superiors, and I hid behind their authority with relief.  With no power came no blame.  I would offer sympathetic eyes during the blow-outs and weigh how much of what the patient perceived was in line with reality.

The last two episodes were on an entirely different level, not because of their intensity but because no one but me stood there to shoulder them.  Now I see patients alone and project a greater air of confidence, which naturally leads some to believe that I am the one making their decisions.  My usual intellectualization and analysis were non-existent; I experienced a pure visceral response.

The first episode, in retrospect, was merely a preamble.  I walked into the clinic room and was greeted with “You’re 45 minutes late.”  I apologized.  The patient insisted I wasn’t sorry but that I was unprofessional.  I don’t quite remember all the personal attacks he added over the next few minutes because my sympathetic system had taken over: my cheeks flushed, my heart pounded, and all I wanted to do was flee.

I managed to squeeze out that we were running  behind because we spent more time with sicker patients than we had anticipated.  What I wanted to add was that he was setting us more behind.  What I wanted to add was that even though his appointment was only for 20 minutes, we would spend more than 20 minutes with him, like we did for every patient.  What I wanted to add was that his behavior was self-fulfilling: suddenly I wasn’t sorry anymore.

Instead, I withdrew.  I’m fairly certain I took a less thorough history with him than I do with other patients.  I’m pretty sure my plan was more rushed since he questioned my judgment at several junctures.  I know that all I wanted to do was get out of that room and away from an unpleasant person that I had originally wanted to help to the best of my ability until he compromised my ability to help him.

The following day, I was back in the hospital with a much sicker patient.  I walked in to do a physical exam and the patient demanded that I get him food.  I explained that he couldn’t eat independently because he was at severe risk for swallowing the wrong way and having the food go into his lungs and causing an infection.

“You f*cking b*tch,” the patient yelled as loudly as he could with his weakened voice as he tried and failed to get out of bed and reach his food.  I apologized and once again I heard the cutting response: “You’re not sorry.”

Again, I felt the familiar flushing as the patient called me creative names and instructed me to do creative things.  This time, I had no response at all.  After the first minute, I felt sorry that the patient was hungry and couldn’t eat.  I felt sorry that he had such poor hand dexterity that he needed someone else to feed him.  I felt sorry that he didn’t deserve the medical hand he had been dealt.

After several minutes though, my empathy faltered and finally gave out.  My thoughts turned from the patient’s plight to a more inward stance: I don’t deserve this.  That single thought amplified until the hungry patient in front of me no longer existed.  I don’t deserve this.  I knew it wasn’t personal because he would have screamed at anyone who happened to stand in my place.  But at the same time it was personal because it happened to be me.

I didn’t say much and walked out, feeling shaky.  More disturbing thoughts snaked their way into my consciousness and wouldn’t let go.  No, I wasn’t sorry anymore.  No, I didn’t really care what happened to him.  And then probably the worst thought I’ve ever had in my life: in that moment, I didn’t really care if he lived or died.

With that realization, I found a bathroom to cry in for about half an hour while I ignored the page from my resident inviting me to get lunch.

Within an hour, my limbic brain had yielded to my cortex and I was able to analyze what had happened.  Ironically, it was the analysis rather than my raw emotion that brought back empathy.  I reread the patient’s notes, talked to his son, and felt as though I had a better grasp on the reasons behind his intense anger.

Within a few hours, the patient was transferred to the ICU.  (Thankfully, the turn of events was unrelated to the care I did or did not give him.)  Half of me felt sorry but the other half still felt relieved that I would not have to see him again.

During our psychiatry rotation, we had had a lecture on how to think about “difficult” patients.  We were encouraged to think about the feelings of helplessness, uncertainty, anxiety, and fear patients felt, in addition to the destructive medical processes impairing their minds and bodies.  We were told never to forget that context when we dealt with someone whose behavior didn’t conform to our expectations of how a “good” patient should act.  It was a very valuable lecture, and I sat in the safety of our conference room absorbing it.

On the floor, feeling vulnerable and alone, feeling attacked and helpless, I lost sight of that lecture.  I was feeling the same things my patient most likely felt, yet to a fraction of an extent.  Although I didn’t verbally abuse anyone the way he did, my internal verbalizations were probably just as abusive.  Destruction need not be loud and it need not be an action.  Perhaps it begins with a thought,  one that snakes into your consciousness and amplifies.  Perhaps it ends in inaction, with you walking out of the room too early.

On the first episode of Scrubs, one of J.D.’s first patients passes away suddenly from a pulmonary embolism.  He narrates.  “I’ll never forget that moment.  The way he looked exactly the same only completely different.  The shame that all I could think about was how hard this was for me.”  Seven months after I have started this thing called hospital medicine, I have finally felt that shame.

Before I wrote this post, I checked on that patient’s status.  He had recently passed away.  I hadn’t known.  It hadn’t been an expected event.

I wonder if I had known how close he was to death if my thoughts of him would have changed in that moment when our lives intersected.

I also know that the answer shouldn’t matter.

Here’s to the start of being the bad guy with good intentions.  Here’s to the start of trying harder, of keeping those good intentions during the most difficult moments–those when no one else believes you have them.

Note: Certain patient details have been changed to preserve anonymity.

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“By the way,” my chief resident told me on the first day of my inpatient psychiatry rotation, “don’t lick your lips in front of him.”

“Wait, what happens if–”

I fell silent as the patient walked into the interview room.  The resident wanted to discuss his paranoid delusions; the patient wanted to discuss his discharge.

The patient wasn’t ready to leave because the medications that made the demons stay away were also making his muscles twitch involuntarily.  More drugs would have to be added to his already potent cocktail to counteract the side effects.  The upside was that this week at least there was no poison in the water.  The military was still lurking in the background, though, and they probably would be no matter what dose of drug we overwhelmed his synapses with.

He raised his voice in frustration, his tone becoming more urgent, his speech rapid as he described the soldiers who were stalking him.  “They’re so smart, they’ve got you convinced you that they’re a delusion.”  He leaned forward.  “Everyone can hear them, but I’m the only one who can admit the truth.

“And I am getting pissed off.”

I didn’t utter a word, but I had never been so aware of my tongue in my life.

Three days earlier, I had finished my surgery rotation.  Suddenly the rules and culture I had absorbed for the previous 12 weeks fell away.  On the inpatient psychiatry ward, a new code governed not human anatomy but human behavior.

Although the outside door was locked, patients here wandered freely from room to room.  Upon entering, I brushed past the security guard outside the door of the isolation room, past a few small rooms with games and crafts, past the large main room where a flat-screen television hung on the wall and where meals were served.  I wandered into a spacious conference room that sometimes doubled as a group therapy room.

I peeked into the “Oasis Room,” a smaller room where each patient was interviewed daily by physicians and social workers.  It had no windows, but it was lit by an overhead light with clouds on it.  The walls and overstuffed chairs were a soft green.  A painting of trees covered an entire wall.  This was the official interface between doctor and patient.  It was designed to be comfortable and non-threatening.  Most importantly, it was designed to optimize treatment.

I thought of the surgeon’s “Oasis Room”–the operating room.  It too was comfortable and non-threatening, but only for the unconscious patient.  An awake patient, while sedated and being wheeled in, was warned, “Okay, bright lights and cold room.”  Before falling asleep, a patient once commented on the dozens of sharp tools that rested on a table near her barely draped body.  Sterile and sensible, though, it optimized treatment.

And there was the patient.  Anesthesia gave ultimate behavioral compliance.  Chaos in the operating room meant a nicked major artery.  An abdomen full of feces.  A heart that beat wildly out of rhythm.  These things were scary because they were unplanned, difficult to control, and physically dangerous.

But on my first day of my psychiatry rotation, without any of these risks, I was scared.  Patients with minds very different from my own roamed throughout the unit.  Sometimes they interacted with me.  Meanwhile, I struggled to look like the “Oasis Room”–comfortable and non-threatening.  I now worked in a world where licking my lips could mean nicking a major artery.

After I interviewed a patient, my attending gave me feedback.  “Patients, especially the paranoid ones, watch your every move.  They are afraid of being judged.”  Though my words were appropriate, my body language could have been construed as suspicious.  I had jiggled my leg.  I had rubbed my boots repeatedly.  I had scribbled down too many notes.

On my first day on surgery, I accidentally brushed the sterile sleeve of my gown against an unsterile instrument.  The nurse had hurried to find me a sterile sleeve to slip over my contaminated attire.

On psychiatry there is a whole new set of ways to contaminate your environment.  Situations can escalate and human behavior, like the heart, can beat wildly out of rhythm.

There are new ways to interact with your patients.  You peer inside them, but it’s no longer literal.  You trace boundaries, but around their insight and judgment and not their vessels and ducts.  You try very hard not to sever anything crucial.  If you do, you pray that you can reverse it.

Instead of anesthesia, we have motivational interviewing and mood stabilizers.  We do not wear gowns or gloves or even white coats.  There is only one item that designates our role: “Without your ID, you are a patient,” my chief resident told me.

The rooms have changed.  The rules have changed.  The relationships have changed.

I am ready to change.


Note: Certain patient details have been changed to preserve anonymity

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Waking Up

An elderly man startles awake after a man in a white coat touches his shoulder.  He looks around and sees three other white-coated people standing around his bed.

“Sir? Good afternoon, sir. How are you?” says the man who touched the patient’s shoulder.

“Oh, I’m fine.”  He’s perfectly calm.

“I know this is a silly question,” continues the man, “but do you know where you are right now?”

“Of course, of course. I’m at home.”

The slightest pause. “Sir, you’re in the hospital.” The man in the white coat names the hospital.

“Oh yes, the hospital,”the patient agrees. It’s as though being at home were just a slip of the tongue and not the mind.

“Do you know why you’re in the hospital?” the standing man presses.

“I’m here… I’m here because you’re giving me circulation to my leg.”

“Actually, you just had an amputation of your leg.”

The patient’s expression freezes, but like many people with dementia, he covers whatever internal processes he has.

“Your leg was just amputated.”

This is not the first time the patient has woken up after his surgery.  According to the nurses, he had been tearful all day trying to cope with the loss of his leg.

“Can you repeat that after me?  Your leg is amputated.”

The patient repeats it, in a tone that I’ve used to talk about the weather.

“Okay?  Your leg is gone.”

And just for good measure he lifts up the blanket and shows the patient the nothing that is there:

“Your leg is gone.”

The doctor turns and leaves.  The other people in the white coats who are not in the patient’s home not giving circulation to his leg follow his lead.  The whole encounter takes no more than 120 seconds.

The third year medical student in the white coat looks back at the man’s frozen expression. With this glance, she has already fallen out of step with the team.

A social worker enters as we leave, pulling the curtain around the patient’s bed.

A curtain around a man who doesn’t wake up from nightmares but into them.

Someone please tell me.

Someone please tell me how to make a box in my mind and put patients into it and seal it and make the patients stay in there until I say they can come out and–actually, on second thought–maybe I’ll just never let them out.

Because I am having nightmares too. But at least I am waking up in my home with both my legs still there.

Someone please tell me how to steel myself against this profession I have chosen.

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Pain Control

She had only been in the hospital twice in her life: once when she was nine and now, 60 years later.  She had gotten tonsils out then.  She was getting tumors out now.

Her abdomen hurt when she was awake.  Her abdomen would also hurt during exploratory surgery, although she wouldn’t be able to feel it under general anesthesia.  Her body would feel it, though, and could respond by dangerously spiking or plunging her vitals.  She needed an epidural before surgery to keep the pain under control.

In the pre-surgery holding area–a busy room with twelve beds and dozens of doctors and nurses–we pulled a curtain around her bed.  She ungowned, naked in the back and naked in the front.  Two anesthesiologists stood at her back, setting up the epidural kit, feeling her back for bony landmarks, and scrubbing the area of insertion clean.

She bowed her head, waiting for the “pinch” that the doctor said she couldn’t promise wouldn’t hurt.  She held out her hands, and her adult niece knelt in front of her, squeezing them.  Her niece quietly spoke about people and places they knew.  “Do you remember Sarah?  Did you know that on her first day as a nursing student, she fainted when she saw blood?  She must have toughened up since then, don’t you think?  I hope so.”

On the rear side of her, the needle missed.  Another shot of local anesthetic was given–another “pinch.”

“You’re being so good.  Things have changed a lot since you were last in the hospital, haven’t they?  You know what we can still do, though–get ice cream when you’re out.”

Whispers, instructions, and concentration from the back.   More slowly, the needle went in. It didn’t miss.  The catheter was threaded in soon after and taped in place.

“Look, that wasn’t so bad, was it?  Just a pinch going in.  And now it’s done, and soon enough you’ll be back from surgery, and I’ll be able to see you right after.”  Her niece didn’t let go of her hands.

I stood at the foot of the bed, splitting my gaze between the technicalities at the back and the interactions at the front.  Trying to glean how pain control came from both ends.

The patient regowned and lay back in bed.  Her mouth politely smiled but her eyes stayed anxious.  The anesthesiologists walked away for a moment to do their final preparations.  The patient and her niece looked at me.  “So, do you know what you want to do with your life?” the niece asked.

Some combination of front and back, I thought.  How and what remained vague.  But I knew one thing for certain.

“Something where patients are awake.”

“We won’t tell them,” the niece said.

Note: Minor patient details have been changed to preserve anonymity.

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I pull up a test result for my patient, and the senior resident standing behind me lets out an excited squeal.

“I’ve never seen the imaging come back positive for this,” she says.  Our two-week-old infant, who already has a rare infection, also has a rare associated structural abnormality.  It’s not benign, but it is fixable.  The fix usually requires surgery.

As we walk over to the patient’s room to update her mother, my senior gushes about the zebra that was uncovered on the ultrasound.  She asks me if I’m excited.   “I dunno,” I mutter, which is somewhat more diplomatic than my discomfort that she is.  “Her kid has to get surgery now.”

But in the room, the resident says all the right things to the patient’s mother, with the right amount of explanation, reassurance, clarity, and tone.  She shuts the door and looks at me, finally, in sad contemplation.  “Let’s give her a bit.  I think she’s going to cry now.”

Since I work at a well-known teaching hospital, we get referred many cases you only hear about in textbooks.  Perhaps I’ve gotten spoiled: on my first day I picked up a teenage patient with a chronic disease with an incidence of 1 in 200,000.  Yet it wasn’t until my third week that I saw my first child with asthma–a condition that is 20,000 times more common.  A resident with four years of practice, meanwhile, has treated thousands of asthmatics, thousands of stomach viruses, and thousands of strep throats.  Seeing something for the first time in years must trigger that flurry of novelty that I still get on a nearly daily basis.

This rationalization does nothing to quell my unease that a doctor’s initial reaction to an unusual and undesirable test result was happiness.

Excitement about anomalies crops up in different ways.  Recently, a resident reported being “obsessed” with a patient’s cough.  He took a thorough history and physical exam, scoured the literature, wracked his brain.  He wanted the cough to be tuberculosis.  He tried to make the pieces fit the diagnosis, but they weren’t quite the right shape.

Why the desire for the cough to be more than just a cough?  Cinching an esoteric diagnosis is fulfilling.  If it is a dangerous but treatable disease like tuberculosis, then I imagine it is even more fulfilling.  In this case, perhaps obsession drives better patient care.  In fact, there is a school of thought that the best doctors are the most curious ones, and I don’t disagree.

But the conflict remains.  Do we wish an interesting tragedy on a patient over no tragedy at all?

“To be a doctor you have to be aroused by sickness,” my classmate told me.  I felt the unease creep up again.  “I’m aroused by making sick people better, not by the sicknesses themselves,” I shot back, sounding a bit more confident than I felt.

My 1-in-200,000 patient had infected lungs.  With what, we weren’t sure.  We took his chest x-ray to a radiologist.  The diagnosis was inconclusive.  “It’s an interesting case,” the radiologist said, looking thoughtful.  I thought about the interesting lungs belonging to the interesting patient.  He was upstairs playing Wii, unaware of just how darn interesting he was.

Can I simultaneously be fascinated by sickness and also wish it didn’t exist?

On one of my first days on surgery, I was stitching up a patient’s abdomen when I felt a sharp twinge in my finger.  I peeled off my gloves and saw a drop of blood that wasn’t the patient’s.   I uttered a few choice words under my breath, scrubbed my hands like Lady Macbeth, and went to the emergency room.

The chances of someone having HIV are 1 in 200.  The chances of contracting HIV via a needlestick are 1 in 300.  As of today, there is not a single documented case of HIV transmission using the particular needle I did.  If I get it, I would be really interesting.

I wonder if somewhere out there a doctor’s subconscious is rooting for the zebra that could kill me.

Note: Minor patient details have been changed to preserve anonymity.

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He was nervous about having his uterus and ovaries out.  I had gotten on well with him in the surgical holding area.  I didn’t get to ask what I really wanted to, instead skimming over shallower subjects like where he was from and who each person was who had to examine him before surgery.

He finally asked me if I had ever treated a transgender patient before.  I told him that I hadn’t.  I added that he would probably forget me in the haze of people while I probably would remember him for the rest of my life.  I’ve been saying that a lot to patients lately, since each one is usually my first something.

“How do you feel about seeing me?” he asked.

Seeing him?  I didn’t feel anything different, I said.  This was true for him as an individual.  On a larger level–seeing what he represented–I did.  I have strong feelings about our national squeamishness about sexual orientation and gender identity.  This was not the time or place to mention that, as he was getting drowsy from his first dose of medication.

Twenty minutes later, he was asleep in the OR and completely undraped, ready to be prepped for the incisions.  All of a sudden, he materialized as an individual patient, allowing himself to be opened up and treated.  No longer was he a political or social statement on society, or necessarily all of the qualities I wanted to project onto him.

About thirty seconds later, the resident said to me, “You need to find things to do.”  It was rare feedback, because I am usually the one moving the bed to the hallway, putting boots on the patient to improve circulation, and taking apart the table.  I looked up, and all of those things had been done in the half minute my mind had been undraped with the patient.

I get it. The OR is not a place to reflect, if only for seconds.  Patient care depends on it.  I get it, but on some level I think I resent it.

The rest of the surgery was no different from any other.  His uterus and ovaries looked beautiful and healthy, and of course this was irrelevant.

Sometime during the closing of the incision sites, I thought of the Na’vi casual-yet-profound “I see you.”  For some reason, I saw this patient when I looked at his body rather than into his eyes.  Humanization and objectification entangled themselves in ways I’m still trying to sort out.

“How do you feel about seeing me?” he had asked, and I had answered.

Ask me again.


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