Tuesday, December 18, 2007

My First Time

I remember my first inpatient experience well. The patient is burned into my mind as a constant declaration of the ignorance that I held entering the clinical aspects of medicine. To be honest I found this person disgusting, repulsive, and inhuman. A perception that I did not wish to have betrayed to my superiors or my patient.

This feeling was uncomfortable and appaling. Over the last 2 years I’d been indoctrinated with the ideals of the “ethical physician” and the “professionalism” I must inculcate before meeting real patients. Despite the many fantastic thoughts and discussions we as a class had entertained, these forums, as well meaning as any, were utterly useless upon this first meeting.

Homeless, IV drug addicted, and crippled with disease, the patient came to us earlier that morning while I oriented to the inpatient wards. Upon entering the room I beheld a haggard, disheveled, and desperate form. Reeking of a filth known only to years of hardened drug use, I realized and withheld the primordial urge to retch and vacate the room.

“A full history and physical.” was the task charged me by my senior resident. "You will need to get a full H&P, write it out, and present it to me later today along with a differential and plan." Considering I'd never done a full blown physical, I knew I would need at least an hour with this patient and was not looking forward to our prolonged encounter.

Even though the intern was finishing up his H&P when I entered, I had to revisit every last detail already procured. The patient, clearly upset over this obvious intrusion, deferred several questions, cursed my stupidity readily, and resisted any attempts at a full physical. The anger inherent in the eyes was penetrating. Trust was not given nor expected, just more hurt, and he wished to inflict it before receiving.

Over the next week and a half “my patient” grew more tiresome. Pre-rounding was endless, useless, and ultimately absurd. The only information gathered was from forcing myself on the chest wall, abdomen, back, and head in order to elicit the heart sounds, breath sounds, and other physical tasks requisite of me after questioning the lethargic night nurses for overnight events.

Once able to hold a semblance of conversation, my patient soon withdrew from everyone and became mute. On one occasion I found my senior yelling in exasperation as she attempted to get consent for treatment. She no longer rounded unless the attending requested – leaving only the intern and I looking after the patient in the early mornings. The hate emanating from those eyes was palpable. We all felt it.

Regardless of the hate, the battles, and the apparent lack of concern about their declining condition the patient did not leave. Eventually a surgeon at another hospital agreed to fix the problem, and they were thankfully transferred off our service.

A month later, while on surgery, I heard a coarse, rough, and demanding voice yelling from a room.

NURSE!” it boomed out of the darkened room. Despite the days of silence, I still instantly recognized it as my former patient’s.

My first instincts were to walk away and ignore the voice. I was no longer on this service and thus, not responsible for this patient anymore. However, for reasons still unknown to me, I walked into the room.

Upon my entrance I felt the same misgivings I had previously. There the patient was, improved in some ways, but in others very similar. I wondered if the reasons for another hospitalization were due to drug use and thought quickly about the cost of treatment they’d received that would surely never be collected.

I informed my former patient that I was not the nurse, but would let them know they were needed. Then, turning to leave, I said as calmly as I could:

“I hope that you’re doing everything you were asked to get better. A lot went into your care to get that surgery and I don’t think you realize how hard it was to get that taken care of…don’t blow it.”

I then walked out. A part of me felt vindication – speaking out against the wretch who hated those trying their best to improve a hopeless life. However, another piece of me knew that my innocence of doctor-patient politics had been forever lost. The urge to “want to help those in need” had been challenged and clearly weakened. By saying what I did I had only perpetuated its decay, amongst both parties. Despite knowing that I should have remained silent, I felt the need to let this person know were tried for them. We worked hard, against a system designed to hinder progress and I was upset by their seeming displeasure of my team's daily work.

This patient still haunts me. I’ve not seen them since, but I frequently think of them. I did not hate this person, but I entertained such desires at times. In my innocence, as a 3rd year medical student, fresh on the hospital wards, I wanted my patients to want to be helped. Furthermore I hoped that they would appreciate our efforts. Unfortunately I learned that it’s not that simple and patients, like those caring for them, are people first and foremost. Some are just better than others.


Ladyk73 said...

He seemed like a handful.

I'll give you the empathetic social worker type prospective. I think everyone deserves respect and dignity.

(Doctors included)

Sometimes people need to hear the unpleasant truth.

Liana said...

I've been there. Oh man, I've been there. But presumably, this is why you and I made it through the pack of medschool wannabes... someone on that admissions committee looked at us and figured that we had it in ourselves to treat with compassion someone who, if passed out on the street, most people would just step right over.