On a different note, I thought last week that I would have to blog a little about the intensity of some of the things I experienced caring for my patients. Time and space has mellowed that out a bit. Still, I do want to mention it, more for myself in the future (if I ever bother to reread this) because I would say that it was one of the most defining experiences I've had so far this year. It reminded me about why I went into medicine, why it will always be a challenge, and how I am starting to form into the doctor I hope to be.

During my last four weeks, I had an 85 year old patient I grew close to, partly because he was sick and partly because he was my patient for the entire time I was at that hospital. When I met him, he was just starting to overcome a bad infection. He was in the ICU, barely able to sit up, but getting hopeful about gaining strength and the ability to eat within a few days. By the end of the week, he hadn't gotten better. He was sick, exhausted, and scared. I would round on him in the morning, his body swollen from fluids we couldn't diurese, and he would lie in bed, tense and agitated, moaning. He had been functioning very well before his infection. He lived on his own, though he often visited his adorable petite 82 year old girlfriend, and he was careful about his health. But he was still in his 9th decade of life, and his body could not recover from what had hit him.

My resident and I spoke with him on one of those days, when he sat up in his chair, moaning and clutching the armrests tightly. We couldn't figure out what was wrong with him. He looked depressed and exhausted. Finally, he said he was scared - scared that he was never going to leave the hospital. He was still in the ICU at the time, and a decision was made to get him out of there. The ICU can be an exhausting and depressing place. The lights are always on, people bother you at least hourly, and there are beeping noses everywhere. Neighboring patients code and die, and new ones are brought in. He had been in there for nearly 10 days; a healthy person could have gone insane. We moved him up to the floor, and one the first day, he had the biggest smile I had seen. But he didn't get better, and as he continued to decondition, he started to get worse. At the end of his second week, he went into respiratory failure, and we had to intubate him and return him to the ICU. He extubated easily, but was even more weak and sick. He had a pneuomonia and fluid in his lungs, and he continued to be overloaded with nearly 10 liters of extra fluid that we couldn't get his kidneys to excrete.

Eventually, he got well enough to go to the floor, but two days before I left, I found him incoherent and unresponsive, and we had to intubate him again. I called his family, and when I met them in the hospital hallway, we all began to cry. I didn't want to scare them, but I couldn't handle it at that moment. When he had told us a few weeks before that he didn't think he would make it out of the hospital, my resident and I really thought that he would. It was so frustrating to have failed him. I wanted to keep giving him another chance, but I knew that his chances were fading quickly. I talked to his family about changing his code status to DNR/DNI - do not resuscitate or intubate - so that next time this happened, he would not have to get back on this rollercoaster again. We agreed that it was best to let him decide, if he was able to recover enough and get off the ventilator.

When he woke up again, on my last day, he had tears in his eyes and he struggled to speak against the tube in his lungs. You could see his frustration and fear, and it was one of the most heartbreaking things I have ever seen. I felt ridiculous having to tell him that I was going away - as if that mattered - but somehow it did, to everyone in the room. As the medical student, I had far more time than the residents or doctors to spend with his family and him, and we had all grown to know each other. I had fought hard for every lab value and study, every dose of the medication he would get, so that he would get the best care our team could give him. And he still got sicker. There was really nothing we could do, and as I left him, I could see that the struggle - which had become so much of his pain and frustration at this point - had begun to calm in him. I don't try to convince myself that the fear and sadness were gone, but I almost feel that my leaving gave him permission to rest.