Knowledge is Power

I met him late one night. I can be honest and say that I was not thrilled to be getting an outside hospital transfer at 11:15pm. Nevertheless, I walked into the room to find a 54 year old man who looked 70. He came in with the simple plan of continuing treatment for his bacterial endocarditis. Easy right? Place a Hohn, get him in, and get him out. He was grumpy and he wanted to go home. He certainly wanted nothing to do with me.

Want me to list his problems? Well, that might take awhile because that simple bacterial endocarditis turned out not to be so simple. He had BPH, ATN, AIN, neurosyphilis (which I proudly (?) diagnosed), alcoholic cirrhosis, HCV, ESRD, congenitally born with one kidney… should I go on? Let me sum it up: a bad liver, a worse kidney, and a youth spent boozing, sleeping around, and suing the pants off any employer he ever worked for.

I wish I could truly share the experience that I had with this patient. I was pulled aside by almost every member of the nursing staff begging me to send him home. I walked in on him screaming on the phone to get Tom Martino to help him sue DH. I walked in on him sleeping. I walked in on him listening to Johnny Cash. I walked in and sat down and watched “Sleeping with the Enemy” (twice) and three old John Wayne movies. I spoke with him about his past. I spoke with him about school. I can still hear him saying “knowledge is power.” Despite all of the nursing pages to “run down quick,” I felt a strange sense of pride that MY patient would only talk to me or to Dr. Albert. (Dr. Albert and I on the same page?! How could I not smile?)

I remember that after fourteen days, I wrote his discharge paperwork. FINALLY! He was doing better; he would be going home tomorrow morning. I would be sad to lose my first “real” patient, but at least I “fixed” something.

I walked in the next morning to a scene I never expected. He did not remember me. I remember starting rounds with my team and begging them to see him first because I was so concerned. Everyone on the team knew what was going on but me - hepatic encephalopathy. I was scared that I would lose my patient. I pumped him so full of Lactulose that I never thought anything else could come out of him, but he got better. I felt triumphant. I once again had diverted the impeding doom. I could laugh. I could sit back and talk with him at the end of my day. But let’s admit it, my naiveté did not allow me to see the real picture: something was really wrong.

Day by day I started to see problems with his morning labs. They were not cooperating with what I wanted to have happen. I wanted him to get better and get out of the hospital. One of those “nice to meet you but I hope I never see you again” deals. It was all going downhill fast, but I still had hope. Heck, we fixed his prerenal, we fixed his renal, we fixed his postrenal problems, we fixed his hepatic encephalopathy, but damnit - we could not fix the big picture. I remember the day when Dr. Albert told me that my patient would die within two weeks. My interns gave him a week. WHAT? How did we change within the week from planning to discharge him to he is going to die?

Within the next couple days hepatorenal syndrome was diagnosed. Somewhere, someplace there must be an answer. Vasopressin drips with albumin in the ICU? Sounds good. Sign him up. Let’s go, but first came the end of life talk. It was only fair to share with this man that had fought for everything his entire life that he should now choose the arena for his final fight. Would it be at home? At hospice? Or with me and a team in the ICU? He chose me.

At this point he was out of my care and sent to the ICU. I remember pulling a chair up next to his bed in the ICU daily and watching movies on AMC before I would go home. I remember my last day - July 28, 2006. I was done with all of my work, I said my goodbyes to my team, my CMR, but I left the biggest goodbye for last. Three and a half weeks of daily interactions with this one patient; I walked to the ICU feeling like I was about ready to abandon someone that I thought needed me so much. I pulled the chair up next to him and we chatted and watched another John Wayne movie. Sure it was 5:30pm and I wanted to meet my friends for a beer, but I knew that they would be there, but this moment - this simple moment - was something that could not be replaced. He cried and talked about wanting to give his nephew his stereo and how he finally decided to donate his body to science. I just looked at him and I had to choke back every tear that was threatening to slide down my cheek. I looked at him and thanked him for giving me the greatest gift he could give me - knowledge. He gave me knowledge of the kidney, the liver, the difficult patient, of the pains of medicine, of how to be a “doctor.” Here was a man that never had a formal education and during his hospital stay he became what he always wanted to be: a teacher. I told him of how he gave me the foundation of my knowledge in clinical medicine, and that he would not be forgotten. What greater gift could a patient give you? One movie later, several conversations laughing about life - I had to leave. I had to learn to let go.

I walked away from DH thinking about how much I had learned. How I feared being at DH for Medicine (it was ranked last on my list of hospitals), but with the feeling of such excitement for what the rest of my third year would bring. I walked away thinking that my patient would be one of those lucky ones - one to be cured. I was able to relax because I felt all would be well. It had to be.

I went home - back to my life. My “other life.” It was great to be able to sleep in for a day and to not worry about being pimped by another Attending. I could sit down with a cup of tea, read my email, and catch up on the rest of life. I did not think that anything from my hospital life would infiltrate this Saturday morning, but then I saw an email from one of my old interns. Mr. M. passed away. I felt guilty for not being there. I felt like it was a joke. After the initial shock wore off, I had to smile and shake my head. He could never die. Every day of my life he will be with me because of all that he taught me. Knowledge and memories make him immortal. Thank you Mr. M.

- Rebecca Susan Vogel