I often compress my workday into a vignette involving a patient that has given me pause and made me think. Here is a scene from several years ago......
The room was dark and full of shadows. The man lay in the large ICU bed, turned half way onto his left side, eyes closed, the plastic oxygen mask covering the lower half of his face. His body looked much smaller from the last time I had seen him as if something had come along and deflated him. The monitor above the bed was quiet, but gave a running update of his vitals. The curtains at the window were drawn so the winter light could not enter the room. The overhead lights were dark and the only light there was came from the doorway that faced into the hall. We stood as a group around the bed, two nurses and two physicians, discussing various aspects of his care including his persistently low blood pressure, the feeding tube, and the fact that he was too sick to withstand surgery for his ischemic gut. The distal 20cm of this man’s colon was dying and as a result, he was unable to control the stool that leaked slowly out. A rectal tube was inserted to try and contain the mess. A smaller Dobhoff tube snaked out of the man’s nose, filled with the brown liquid that would drip into his duodenum and give him nourishment. The conversation revolved around trying to keep his blood pressure up so he could maintain an adequate blood supply to the ischemic colon in the hopes the damaged bowel would not get any worse. The decision was made to restart the second agent to keep his blood pressure in an acceptable range. This same vasopressor had been discontinued only less than twenty-four hours before.
During the conversation at the bedside, the man never moved, never changed his expression, never made any indication that he heard or understood the words that were being said in his presence. He had Down’s syndrome and had already lived beyond his expected years. Not many people with Down’s live into their fifties. How much of the conversation would he understand even if he was completely well?
The room was devoid of any personal objects and trinkets that often accumulate from family and friends while one is in the hospital. He has no family; his only guardian having passed away several months ago. He is a ward of the state. It will be a judge who will make the decisions regarding this man’s care. Someone completely unknown to him who will simply follow the letter of the law in prescribing what will and won’t be done with his medical care and his life. Would the judge ever consider coming to visit the man as he lay in his white hospital bed, blue gown covering his thin arms? Would the judge stand at the bedside, take the man’s hand into his, and squeeze it? Would the decisions made be any different if he did? Would a look at the rectal tube change his thinking?
The four professionals standing around the bed paused in the conversation at the same time, almost as if on cue. The one nurse remarked that she was afraid he would have to be intubated again at the rate the day was going. The others nodded in agreement. They decided to restart the second medication again to correct the low blood pressure. They decided to suction him if needed, probably disturbing his sleep. The four of them slowly drifted toward the doorway and out into the lighted hall. The man remained laying in his bed, quietly breathing, not moving.
I don't remember the ending of this story, except that I think the patient eventually died from his illness. Many people are lucky enough to have family and friends surrounding them during their illnesses, but many more do not. As physicians, I wish we were more comfortable going in and simply holding a patient's hand for a few moments, but we are often taught to separate ourselves from our patients. This message is conveyed to us throughout our training, often simply by the means that we are too busy trying to get the next patient seen, the next lab ordered, the next dictation done, the next family member out of our hair.
A wise physician once said to me; "Listen carefully to your patients, for 99% of the time, they will tell you what is wrong with them." What do you suppose the man with Down's Syndrome in the ICU bed was trying to tell us? And why did we all drift away from him so quickly?
No comments:
Post a Comment