Yea, though I walk through the valley of the shadow of death,
I will fear no evil
For Thou art with me.
Thy rod and Thy staff, they comfort me.
Thou preparest a table before me in the presence of mine enemies.
Thou anointest my head with oil,
My cup runneth over.
Surely goodness and mercy shall follow me all the days of my life,
And I shall dwell in the House of the Lord forever.
It is a psalm of completion, a psalm of fullness and fulfillment. It does what “we” cannot do. This week I have come to understand that it is a song that replaces what is lost with spiritual substance. Be it true or not, the elegy provides enormous comfort, for it hints at the eventual restoration of what death has taken away, and what the demons have robbed from us. It promises to give back what we could not.
Limitations
Greg Feldman
THERE IS NO LECTURE during the first year of medical school called “The Patient Whom Medicine Fails.” Mr. Colovos did not initially appear to be such a patient. Mr. Colovos had been hit by a car and had incurred extensive abdominal trauma. Removing his shattered spleen and colon saved him, but several rounds of operations and physical therapy left him with lower leg pain so severe that, at the age of fifty-five, he found himself unable to walk or drive a car. Recently he came in with a urinary tract infection and abdominal pain that we could not treat. We puzzled through several differential diagnoses before a computed tomography scan revealed that his colon was now leaking into his bladder from an abnormal connection called a fistula.
Tucked up to his chest in hospital blankets, Mr. Colovos radiated a bitterness that contrasted with his affable manner toward me and the nurses. Since his accident, he had been unable to continue working, and he was tormented by the constraints of his reduced mobility. The accident made socializing difficult, created tension in his marriage, and left him feeling discouraged and, as he put it, “useless.” He had been given antidepressants, but they had not made any perceptible difference in his mood. A lucrative settlement related to the accident appeared imminent after years of legal wrangling, but he seemed largely indifferent to it.
“What good would a million dollars do me?” he asked. He viewed the impending operation with indifference, as it would preserve his life but would not restore its meaning. “It would have been better,” he said, “if I had died in the accident.”
Grimacing with sporadic waves of pain, Mr. Colovos answered my questions kindly and thoroughly. As we discussed his family, health history, and medical frustrations, his gestures grew more animated and he became more talkative. I noticed a disjuncture between his increasingly lively affect and the substance of his conversation. Finally I ventured the question that had been troubling me.
“What gives you joy?” His response was immediate, flat, and chilling: “Nothing.” Then he paused, and his face softened at the engagingly plump infant in photographs at the foot of his bed. “Except for her—she loves her Papu.” We talked about his granddaughter for several minutes before I returned to the question.
“Nothing else?”
“Nothing.”
Since meeting Mr. Colovos, I keep thinking how, as important as physical health may be, the work that physicians do often seems almost incidental to the amount of joy that patients derive from experience. A life without pain is obviously preferable to a life with it, but Mr. Colovos reminds me how patients’ attitudes toward their conditions may actually be more significant than the conditions themselves for determining what pleasure patients take from existence. I am haunted by words my grandmother once spoke: “People aren’t living longer, Greg; they’re suffering more.”
Surgeons could salvage Mr. Colovos’s life, and they may be able to correct his fistula. Unless he becomes acclimated to the restrictions of his situation, however, I am left with the terrible suspicion that, as he stated, it might indeed have been better if he had died in the accident. I have met patients confronting physical challenges as formidable as Mr. Colovos’s who nonetheless take vibrant pleasure from life. And this reinforces for me how vital is the work of those who seek to treat patients’ attitudes as well as their bodies. I will spend the next few years learning how to make people healthier, and at times this year, I have begun to believe that this really is the calling I am meant to embrace. But patients like Mr. Colovos remind me that seeking to make patients happier may be as important an act of healing as seeking to make them healthier. I hope Mr. Colovos achieves the reconciliation with his condition that he will need to find value in life again.
Autopsy
Christine Hsu Rohde
Motionless, barely warm, almost cold, sheet silhouetting posthuman form,
How many breaths, how many heartbeats ago has it been?
But now, does it matter? Only the answer to why that the bunny-suited MDs seek.
ARDS, PE, MI, NHL:
An alphabet soup of responses
Irony of seeking answers in one incapable of questions
The tired refrain: “Death is part of life.”
Wait. Find life in the no longer living.
The details her lungs will reveal, the insight his bowel will provide,
But without sentimentality: silent affirmation of the prosecutor’s words.
Radio plays “Stairway to Heaven” as the saw grinds at the ribs
Insides removed en bloc
Maybe the next song will be Jewel’s “Pieces of You.”
The dissection begins—
Esophagus, stomach, intestines: the stories they would tell,
Not about H. pylori gastritis or pseudomembranous colitis
Or other too-many-syllabled tongue twisters,
But of Grandma’s famous apple pie, the all-too-spicy buffalo wings,
The once-stuck chicken bone and the bystander who knew the Heimlich,
The bout with the flu or the night of too many tequila shots,
But they remain silent; no one else can give their history.
So the dissectors move on to the trachea and lungs,
His first words, his last words,
Once-vibrant vocal cords. What songs?
Church choir, opening night at the Met, drunken off-key melodies
The laugh: a high-pitched screech, maybe a belly-shaking sound
And the cigarettes—black and mottled remnants of pinkness.
Next the heart,
Not just showing signs of too many french fries
But surely pierced by Cupid
And scarred by emotional infarct.
Did it skip a beat the first time she saw her husband
Or heard her newborn child?
How many times did it race with fear or excitement?
Now the ticktock of the internal clock stopped.
On to the skull, through the dura, removal of the brain,
Recall IT, disembodied dictator.
Every thought, every memory, every fantasy,
In the palm of a gloved hand.
Gyri once bulging with information, now atrophied with age
Brain into bucket—truly lost his mind.
And so it is with the rest: spleen, liver, pancreas, bladder, gonads,
Parts of her, pieces of him, from beginning to end
Full of unspoken history.
The board is cleared,
Slices in formalin, slices on the tray, the rest in the circular graveyard.
The hope that somewhere the memory survives, a legacy remains,
The period a mere beginning to another comma …
The Soul—
Where is it?
It Was Sunday
Tracy Balboni
IT WAS SUNDAY. I entered through the revolving doors of the hospital shortly before eight. The lobby was quiet in contrast to the commotion found there typically during the week. As I approached the main corridor, the quiet gave way to a subdued version of the streaming life of hospi
tal hallways.
A man was lying on a gurney, his mouth wide open and caved in where his dentures should have been. Pushing him was a Haitian man humming a wonderfully sweet tune. Soon after the gurney passed, a doctor strode by looking hurried, annoyed at having to make his way around the gurney, his stethoscope and ID badge thumping against his chest. An old Hispanic woman pushed by with a cart of cleaning materials, seemingly untouched by the busy highway of people moving about the corridor.
I made my way to the elevator, catching the cleaning lady’s eyes for a moment as I passed. She smiled deeply, the lines of her face etching a picture of her soul. I caught the elevator as the door was closing, and found four people staring at me blankly. The five of us looked impatiently up at the numbers as we ascended.
Bigelow 7 is the gynecology/oncology floor, and its beds are filled primarily with terminally ill women. The nursing station was quiet that morning. As I waited patiently for my intern to arrive, I noted the number of patients in house, and I was relieved to find that the floor was not full. I took advantage of this quiet moment to pray silently: Oh, dear God, please help me to make it through this day. I am already tired. Please help me to willingly serve you despite my tiredness. Please help me, dear Lord, to give to the patients as you would have me give …”
My intern arrived, and I quickly lifted up my head without closing my prayer. And so our day began.
By two the next morning, Bigelow 7 was again very quiet. Most of the fires of the day had been snuffed out, or at least were held at bay for the team arriving at four thirty. What was keeping my intern and I up was a woman whose blood pressure we could not seem to control. All evening we had been continually walking in and out of her room, giving her Labetalol infusions and watching her blood pressure. Despite the infusions, her pressures remained high. It was late, and I was tired. The attentiveness of the early morning had given way to a single-minded approach in extinguishing this resilient fire.
The room contained two patients. The far patient was the elderly woman with ovarian cancer, whose blood pressure was not yielding to our treatments. Then there was the woman closest to the door. She was a sixty-year-old woman who had only in the last week been found to have ovarian cancer. I hardly noticed her upon entering the room the first few times, but later in the night, it became more difficult not to see her. She was clearly in a great deal of pain and discomfort, primarily because of her difficulty breathing. It was evident what was causing her shortness of breath: her abdomen was distended with tumor and ascitic fluid. She was unable to sleep despite considerable medication, and she was continually shifting her position in an attempt to get comfortable. Despite her pain, my intern and I did not attend to her. There was nothing left for us to do for her that night, and so I had accepted her suffering without any sense of responsibility. In fact, I had hardly reacted to it at all. It was not her pain, though, that was so poignant to me upon reflection, although my insensitivity to it is now a burden to my heart; it was instead the beauty of her spirit. Her spirit penetrated the wall of my single-mindedness, which had been erected through the day and solidified by my increasing fatigue that night.
Despite the horror of her condition, this woman’s soul was so evidently at peace. She seemed to accept her pain and discomfort willingly and with ineffable grace. This strange peacefulness was what finally gripped me, although I still refused to ponder what had embraced my heart. I was too busy. I was intent on the management of her neighbor’s blood pressure.
But at one point late that night, my intern and I could not ignore her any longer. She was now up out of bed, desperately trying to find a position in which she could relieve herself of her plaguing shortness of breath. She became twisted in the many wires and tubes that fed into her, and we went to help untangle her. In untangling her, I managed to get myself tangled up with her and the wires as well. Given the comedy of the situation, we laughed. Between her gasping breaths, she laughed.
The next day came quickly, after a very short hour of sleep. On rounds that morning, I discovered that she had coded and was now in the medical intensive care unit, unarousable. Later that day, the woman passed away.
I immediately thought back on the night. Tears came as I realized that I had spent the last of this woman’s conscious hours with her. I had been given this privilege, and I had hardly seen her. I thought about all that I did not do for her that night. I did not acknowledge her pain or comfort her. I thought again and again about our short interaction, when we were both tangled in her intravenous lines. I heard her laugh between labored breaths. I realized that I had probably shared her last moments of laughter. I marveled at the beauty and peacefulness of her soul. I realized that even in her last moments, she had given to those around her simply by her spirit.
I walked through the corridor on my way out of the hospital that evening. I once again saw the mosaic of life in the various souls I passed. I silently prayed. I thanked God for the woman who had died and for the gift of her beautiful spirit. I saw His love in the window of her last moments of life. I knew she was now at peace.
By her spirit, God had taught me how to serve as a physician—not with a heart hardened by the efforts to achieve the task at hand, but with a heart opened to seeing with soulful eyes.
Transitions
Kristin L. Leight
WHEN I FIRST HEARD his name, Mr. R. F. Spratt, mentioned on rounds, I had the very random thought that it sounded like that of a Dickens character. So when he became my patient and I saw him for the first time, I was surprised to see that this name suited his bearing. Most notably, Mr. Spratt had an enormously distended ascitic-fluid-filled abdomen. This, along with his fair complexion, his distinguished nose, and his small stature, made him a perfect Dickensian figure. I could easily imagine him dressed in a waistcoat, twirling a pocket watch, swashbuckling about, while rubbing his protuberant belly. Only Mr. Spratt’s oversize abdomen was not the result of gluttony or alcoholic overindulgence, as would have been the case with a Dickens figure; he was the victim of a rare disorder called carcinoid tumor. And poor Mr. Spratt was not swaggering about in a jolly way, as I wished him to be, but confined to his bed in a profoundly sick and stuporous state. He was a prisoner in his distorted body. Every time I saw him, I thought of a turtle on its back; he could barely move, his stomach was so enormous.
Originally Mr. Spratt was not my patient. He had been a “bounce-back” to one of the interns, meaning she had treated him before in the recent past, so he was readmitted to her care, and thus I did not admit him. However, when one of my patients was discharged, the resident suggested I start following Mr. Spratt, as he was a “good medical-student case.” It was so: Mr. Spratt had been found to have carcinoid several years before, when it had metastasized to his liver. He had been treated with chemotherapy, which had been discontinued the previous year because of side effects, and for the past few months, he had suffered from a belly swollen with fluid from tumor invasion of his liver. During the course of his hospital stay, he developed a serious infection of the abdominal fluid and eventually failure of his liver and kidneys. He also had an altered mental state from the liver failure, and a flapping tremor of the hands often seen in patients with severe liver disease. This flapping motion was a favorite physical finding that the residents liked to point out to the students. Poor Mr. Spratt must have started to believe he was a traffic guard, so often was he asked to “stop traffic” in order that we might see his liver flap.
There were only about six days between the time that I started following Mr. Spratt and his death. For each of those mornings, when I would preround on him, I would ask his name, and he would say in a ceremonious, albeit barely understandable, way, “R—— F—— Spratt Junior” He never forgot the “Junior,” not even on the last day. But he did often forget the year and the place where he was staying. I discovered from his wife that he would study for these sessions, repeatedly asking her the name of the hospital and the date so that he could answer correctly. He was p
robably accustomed to having given the correct answer most of his life. It was easy to tell that he was an intelligent and dignified man, and it was heartbreaking to see him confined as he was—by diapers, by restraints (he fell several times), and by his own failing body and dulled senses. The last few days, when he could barely answer my questions, I would, after I examined him, stand with my hand resting on his abdomen, watch his laborious breathing, and try to imagine him as he was in his pre-hospital life. I had surprisingly clear, almost movielike images of him: Mr. Spratt playing with grandchildren, presiding over the turkey at Thanksgiving, grilling in the backyard. And this made me feel strangely connected to him, despite his silence and mine. It is said that the comatose are still aware of who and what is around them, and I hoped that Mr. Spratt, in his stuporous, pained, and nearly comatose state, could detect a presence that wished him well.
When I first started following Mr. Spratt, the attending asked me to give a talk on his history and hospital course and to try to explain what was going on with him medically. I had put it off because his case was so complex; it had required hours of poring over his medical records, laboratory tests, and studies, not to mention the literature on his rare condition. When I finally met with the attending one Friday afternoon, I still did not feel as though I had gotten the big picture on Mr. Spratt. I had not, but the attending was able to see things more clearly. He was able to conclude that both Mr. Spratt’s liver and kidney function were significantly declining and that his prognosis was poor, much worse than the attending had originally believed.
Strangely and serendipitously, ten minutes after our meeting, Mr. Spratt had an episode of dangerously low blood pressure, and the covering intern, who did not know the patient, called our attending to the floor. I happened to be wandering by when it occurred and was a witness to what followed. After the attending confirmed that Mr. Spratt was stable, he pulled the family aside to talk. The day before this, the intern had broached the subject of end-of-life decisions with the family, who chose to take all measures to keep him alive—“full-code status.”
The Soul of a Doctor Page 10
