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Slow.

This past January, I had a knee injury that changed my whole routine. I am a big long distance runner, and used to say that it is the only form of exercise that brings me joy. There is something so relaxing and rejuvenating about a run, especially after a long day of work. 

When I go running, it is my mediation time, my time to recuperate from what is often the emotional and physical turmoil of working in medicine. Even when I feel that the life has been sucked out of me, I will get myself to the park, and run. Afterwards, the feeling of exhaustion has disappeared. I feel stronger, less tired, and more lucid and balanced. On days that I had off, those were my even longer run days. I would make sure my best running shoes were on, my mind was mentally aware of the challenge ahead, and that my headphones were charged. I would be out there for a while. 

January came, and with it came my knee pain. It started out slow, achy, and appeared maybe a few miles into my runs. I can handle this, I thought to myself. It’s just a little overuse, and I’ll just cut down a few miles, a few times a week, and I’ll be okay. I had Achilles tendonitis a year ago, and still powered through the pain, to run the St. Jude’s half-marathon. This would be no different. All I need to do is loosen up, a few miles in and I will feel that runner’s high, and then I’ll be okay. But it became crippling, and I couldn’t even finish a mile. I was not okay. I thought I had torn my meniscus—it was that painful. I was devastated. Running was my joy. What would I do now? When I was once able to run hours on end, now I could barely run five minutes without having to stop, and limp my way back to my car. I would need more than just to “power through this one.”

I turned to my brother-in-law, a physical therapist, and the guy I knew I could trust about this situation. He sent me all sorts of strengthening tips, and stretches to build my knee back. In this time of slowing down, I realized how terrible my form had been the past two years, leading up to this injury. I began to take walks in-between my runs. I began to see the things around me that I had missed while on my long runs, some details of the park mystified me with how beautiful they were, and how I had missed it, even though I had been there almost every day for a run. It allowed me to think more about all the choices I had blindly been making. I began to have work-out days filled with focusing on rehabbing my knee. I learned how much I love Pilates. I changed my running shoes. 

When I used to instinctively tell my patients to go to physical therapy, I now realized the incredible commitment one needs to see the change they want. I felt first-hand the importance of showing up and staying determined even when it seemed like there was no change. It gave me a whole new respect for physical therapy, and gave me the honest experience I needed to genuinely recommend and encourage my patients to try it and to stick to it, if they wanted to see healing. I slowed down, a lot, when I truthfully didn’t want to. I slowed down, and wondered if there was ever going to be a time when I could return to being fast. It was a struggle. I was forced into it. God forced me to slow everything down but I needed this.

I still tend to do things fast. I think it is something that gets pushed on an individual starting in medical school, when you learn so much in such a short amount of time--you learn habits like listening to lectures at two times a normal recording speed to cover more material or to multitask and juggle multiple responsibilities because there is not one, but ten patients that need your attention. To be honest, it seems unhealthy. And that’s because it is. Yet, it is the norm, and it happens. Sadly, I would say it seeps into other parts of our lives unnoticed. If we don’t observe it, we often let it go until we hit an impasse that stops us. We may resist-- we don’t want “it,” whatever the circumstance is, to slow us down. But it may also be the reason for a reevaluation. It comes as a knee injury, and sometimes it can become a precipitant to good changes. We just may need a little slowing down to see it.

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October.

Time is a strange marvel. It takes something so scary and unexpected and makes it feel very soft and distant. It makes the sharp edges more round, and transforms a stabbing pain to dullness. It makes you forget those initially strong feelings. It makes you less full so you can make room for more, more memories that will fill the space--it all comes with time.

October is breast cancer awareness month.

As I get to sit in the University of Colorado Women’s Care Center waiting room, I have time to reflect on how long it’s been since my mom was first diagnosed with cancer. How many times she has had follow ups and mammograms and how many years she’s taken Tamoxifen—can I measure time with how many refills she has had of her medications? And how many appointments have we been to? How many have we scheduled, how many more times will we schedule some more? 

The summer we got her diagnosis, she had gone for her annual mammogram screen. I was working a research internship at the Children’s hospital and was home in Colorado for the summer but had gotten a call during lunch. I remember talking to my mom (who just like me hates going to the doctor’s, scheduling appointments, and doing tests. Getting her to go to her annual mammogram screen was a miracle). She was irritated--the mammogram office had called and asked her to come in for a repeat of the imaging. They had seen something and wanted a better look. I knew that sounded weird, especially as a second-year medical student. My thoughts were foreboding. My suspicions were high. I bit my tongue because I didn’t want to let any of my deliberations out—I most certainly didn’t want my mom to have any negative thoughts about this “second look” when it had taken so much to get her to the appointment in the first place. I could only imagine getting her to go to her repeat…

Instead, I reassured her-- they’d take a second look, and it would be nothing. 

It wasn’t true--I was wrong. After that, there was so much more, so much more that time would bring along. In my heart I knew there would be more and that’s what bothered me--when you get to a new place and you don’t have the same innocence you once did. The meaning of “second looks and repeats”—often these are carefully worded because the medical field has so much more riding on having a secure result. Time has changed a lot of the way I think, and sometimes I am sad about it, because I know that when I hear certain things, they really mean something else, something more. They say knowledge is power. Very few times does anyone explain that it can feel more like a curse.

I sit here in the waiting room on this October morning, for my mom to get her annual mammogram. It is breast cancer awareness month. I'm in the uncomfortable stiff chair, with magazines on the desk next to me untouched. The front desk lady is fast typing away nonchalantly and sipping her coffee casually, as there are no patients waiting to be checked in. Just me and her in the big room. I know there will be another moment when time will temporarily stop for me. It will be as we get the results from this mammogram, five years after she was first diagnosed. Once it does, time will start, right back up again. Moving forward and making room for more. With whatever result that comes back. Softening the memories of our past battles and preparing us for our future ones.

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His Girl Friday.

Intern year is a steep learning curve: part of it is spent acquiring the basic skills to work the EMR, hospital protocol, and rotation logistics and the other is spent fighting insecurities. The identity of a newly minted doctor, when one doesn’t feel anywhere close to competent, is a difficult role to fill. I liken it to a child playing dress up.

In October of my intern year, about four months into being a “real doctor,” I found myself on the Hematology/Oncology Service at the Veterans’ Affairs Hospital. I was following a patient that was particularly fascinating to me for several reasons. One being he had stage 4 pancreatic cancer. He was 87 years old. Looking at him, he seemed much younger. He was spry; his mind sharp as a dagger. There was a gastric mass now compressing his esophagus, and requiring him to have a PEG tube for his major source of nourishment. He was willing to try another round of radiation and chemotherapy, and I often wondered how patients younger, with more fortunate situations, were much less hopeful than this man. Despite his age, PEG tube, and a particularly grim prognosis, he was fighting each day. And he was filled with joy, humor, and fully aware of his circumstances, but peaceful about it.

He fascinated me too because of the way he treated me. I saw him every morning and asked him the same questions about his symptoms. It honestly felt like I was playing a role. Even when others would mistake me as a student, nurse, or CNA, he never did. He called me Dr. Lutchi. Despite my feelings of inadequacy, he insisted I was taking great care of him. When I felt like I was the most useless on the team and that my biggest role was making sure that his bowel regimen was up to par, and his nausea was under control with Zofran, he made me feel as if I was just as important as the physician planning his weekly chemotherapy and radiation schedule.

In our conversations, another fascinating fact was revealed: he was a retired financial planner and he was particularly expert in retirement funds. This was fascinating, because as an intern, this was my first “real job” with a paycheck. And being as excited as I was, I had begun storing away like a squirrel preparing for the winter, some tidbits into retirement. I mentioned it to Mr. D.  His response: give him a call when he gets discharged so he could help me with my future financial endeavors. He had written on a napkin his phone number and in his blue eyes reflected a man who had become my friend.

Mr. D did go home. On the day he was discharged, I remember our conversation: he told me that I was his girl Friday. It made me smile. I realized he was building me up. He was instilling in me confidence. He was pushing me to fulfill my role as a woman physician who had earned her degree, and her position. I was the only one who was keeping myself from truly accepting my role. We both left the service at that point in time, “graduating” from the Heme/Onc service together--him as the patient, and me as the physician.

A few days later, I was shuffling through my papers at my work desk, attempting to organize myself during my clinic week. I came across the napkin Mr. D had scrawled his phone number on. A pang of guilt hit me as I realized I had not called him like l promised. Would he even remember me if I did? Would he recall the insignificant intern who had visited him daily and talked to him about 401(k) and IRA accounts? Would he know how much I valued the way he made me feel like a real doctor, despite the little I felt I contributed medically to his care?

I called; the phone rang. My heart fluttered with apprehension. It went to voicemail.  I tried again. Voicemail. I was disappointed, but relieved too. I wanted to see how he was doing. But truthfully, I was more concerned that he would not remember me. Silly, of course, but these are the things an intern worries about.

Not long after, I ran into a co-intern who was currently on the Hematology/Oncology service, and who said he had read my notes on a patient that had returned: Mr. D. I felt compelled to call him but waited a few days before working up the courage to try again. In the mess at my work desk, I still had the napkin. I tried the number. Disconnected. My heart sank. I remember sitting and calling the number two more times, just to make sure. I somehow hoped for a different outcome—that it would go through. Mr. D would be on the other end, advising me on what stocks I should keep my eye on.

As time would have it, I came across my coresident a few days later. I asked him if he had any updates on Mr. D? He was a nervous one: jittery and quick. But at the name, his face quickly transformed, and he paused long enough for me to know something had changed. He shook his head. Mr. D had passed away. I felt the deep pressure that comes with loss. I thought about my attempts to call, his line disconnected. He had already passed away the day I called, but I had not known.

There’s some patients that leave me, only their faces, or a conversation, or a brief encounter. And there’s some that leave an impact far profound. Mr. D was that way; he fascinated me. And still does, to this day. For the way he pushed me to look past my own insecurities, embrace my role, and realize that it’s not just a costume—I am a physician. I am still thankful for his unwavering confirmation of this.

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#colors

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#waters walk

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#scene redrocks gardenofthegods

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New.

First days on a new rotation seem to have a similar feel. A feel of being completely incompetent and useless. A feeling of being in a new environment, and not knowing where exactly I fit as a medical student. The dynamics of the team requires some figuring out--some observation and testing before I put both feet in the water. I usually have inward complaining for the first week of a new rotation because I am upset with the uphill climb and the newness of everything. It feels uncomfortable. It is not easy. It is stressful. It feels scary. And it is. 

When I started my rotation in fourth year of medical school in the ICU, there was a sense of dread for me that I was again stepping into the unknown. On my first morning, we rounded on a patient who was morbidly obese, and had come in with kidney failure. His newest problem, that his lungs were now failing too, was an unanticipated conundrum to our team. It had come on suddenly. In his room, he responded slowly to our questions, with labored breathing. We told him that we may need to intubate soon, because he was struggling to oxygenate adequately. I looked at him, and tried to understand what a patient who was considered "critically ill" would look like. In my mind, it did not look like this man before me. He was morbidly obese, and filled his hospital bed. He looked like he was not very comfortable, but not due to his health condition, but more from sitting in a hospital bed that was not very large or accommodating for him. If this was the face of an ICU patient, I had the wrong impression of what I thought I would be seeing on this rotation.

The man, who was already on the maximum level of high-flow oxygen, asked us for some water as we were walking away from his room. The oxygen mask was drying him out like a handdryer of a public restroom. I wanted to leave and go find the patient a styrofoam cup of water. The resident and attending were busy comparing lab values and didn't even seem to notice the patient's request. The cognitive dissonance in me was deep. Instead, I followed the team out of the room like a dog at the heels of his owner. We continued to round. As the medical student, being the bottom of the totem pole, and this being my first day, I felt tied. I would follow the lead of the team, who ignored this man's pleas.

Afternoon came, and one thing I had gotten used to as a medical student, is that after you leave for less than an half hour, maybe to do something as innocent and harmless as grab lunch or go to the bathroom, you will find out that your patient had gone to hell in a hand basket, and was shipped to another floor for an emergency procedure or to the cath lab because of an acute MI, or something even more dreadful...I came back from lunch to find out that the man with the kidney and lung failure that I had seen earlier, had been intubated. 

At this point, he was deteriorating fast and his family had decided to withdraw care. I couldn't believe it. My first day, and already a patient was going to die. I went home that day wondering what this new world, the ICU, was going to be like, if this was my first day. 

The dynamics were definitely going to be different. Within the first two days of my rotation, three patients passed away. Another was found to have a rare vasculitis that caused bleeding in the lungs and kidney failure. Something that I had only read about in textbooks, and now was seeing with my own eyes in the form of a young, 28-year-old woman who was prone and sedated, and intubated with bloody sputum coming up the tubes, as she lay on her stomach, “proning” to relieve some of the inflammation in her lungs. 

I felt out-of-place. But intrigued. I was still nervous. I was still stressed. But I was happy. And that was a relief. 

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#beach southpadre breath

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Floods.

The thing about living in South Texas, in the area endearingly called "the Valley," is that when it rains, there will be flooding. It is inevitable. And even though I have lived here for the past three-and-a-half years while attending medical school, and it should come as no surprise, I always seem to think that when it rains, it will be just fine. Just a little sprinkle and then the sun will be out again. Until it's not.

5:45 am: Heading to the hospital. The rains, that can only be described as torrential, have been going all night. There are flashes of lightning and thunder that will explode like grenades. Now it is still running into the early morning hours and the darkness (because the sun is not out at this ungodly hour), makes the rain seem even more ominous and foreboding like the daylight will never come. Not to mention the humidity is at an all-time high. I now I have two things obscuring my view--the windows fogging up and the windshield wipers that are full blast, swinging back and forth, like useless pendulums. I navigate and the drive is slow. Driving my car down the near-abandoned streets, the waters are much too high and uncomfortable for my squat sedan.

The water rushes below the carriage--like a crying whale is following me the entire trip. The waters spray out in waves from both sides like the red sea is being split for the Israelites. I drive through it, hoping that I am still meeting the street and not watergliding like I suspect I am. 

6:15 am: The drive has taken about 15 minutes longer than usual because it has been so precarious, but I have made it to the outpatient internal medicine's parking lot. It's a five minute walk from the hospital and the only really safe place to park as a medical student (security is always on the prowl looking to ticket the inconsequential medical students who are trying to park closer to the hospital). I put on my rain coat, and the hood is pulled tight over my oversized head. Time to venture into the great waters of the Valley.

6:31 am: I have barely made it about 10 feet when I realize that the parking lot is flooded. This is not good, but there is no turning back now. I trudge on and can feel the water coming up to my ankles. It's so dark that I can't tell how deep these puddles are but as soon as I take another step, I sink and realize there's not one that isn't deep and these are not “puddles.”

I make it to the alleyway between the clinic and the hospital, and see a car up ahead is stuck. If a car is stuck, I realize this will not get any better.

6:34 am: A large hummer comes cruising down the alleyway like a beacon of hope and pulls up next to me, a drowning wet cat. The window of the Godsend vehicle drops slowly, and I see the driver is a young man who works in the hospital. He asks me if I want a ride. Normally, getting offered a ride in a dark alleyway is probably a bad thing, but today, I am "swimming" over to that car like I'm Britney Spears circa "Oops I did it again" and have just been offered a pearl necklace from the sunken Titanic. When I hop into the car, drenched, I can immediately see the regret in the driver's eyes. His poor hummer.

6:45 am: I have made it to the hospital very late. I come squeaking into the call room that has linoleum floors, and slip and slide around the room as I try to get logged onto my computer and chart-check before rounds. I will be wet and squeaky for the rest of the day. 

6:30 pm: Driving home, and the water has disappeared. The clouds are gone. There is barely a trace of what has occurred today. Except I know. I know to pack an extra pair of socks for tomorrow. For a rainy day. 

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Words.

I think that words can be hard to find and I've often prayed that God would give me the words when I find myself walking into a patient's room. I don't know exactly what I will say, and I can't just stand around trying to figure out the best words or what a patient needs to hear. So I find myself praying often as I place my hand on a patient's door and introduce myself. Please God give me the words.

There was one woman who was in the ICU for a pleural effusion. This means fluid in the tissue layers that line the lungs and chest cavity. It can fill with fluid for many reasons. All reasons are bad. Sometimes the reason is very clear--a pneumonia that has gotten out-of-control. Other times, it shows up insidiously--this would be like in the instance of cancer. This was the case for this woman I was following while I rotated in the ICU.

This patient had been diagnosed with breast cancer a month earlier. She did not have insurance, and had not started treatment. She was scheduled this day for a thoracentesis, a procedure that allowed us to drain the fluid with a catheter placed between the ribs, drawing the fluid out with the assistance of good ol' gravity. The procedure is therapeutic because it allows the lung to expand and the patient to breathe. The procedure is diagnostic; we often send the fluid for laboratory analysis that can tell us if there are infections or malignant cells present.

My job as a medical student at the time meant that I was there to observe, and help with any of the resident's requests, like getting supplies for the procedure. That day, my job also included holding the patient's hands as we stabbed her with lidocaine and inserted the catheter into her back. I actually really enjoyed this role. To be that person to hold someone's hand. I felt like especially now when our hospital was limiting who was able to visit due to Covid-19, there was more reason than ever to expand my role from just being a supply-gatherer, to being a hand-holder too. To be honest, I found it as a relief. It allowed me time to think. To think of the words.

The resident did the procedure, pulled his gloves off, threw them in the trash bin and left for the next room. It was what residents did--move on to the next patient that needed them-- and there was always one. But for a medical student, I had some time. She was my patient, that I was following--it meant I had the time to talk.

I told her that my own mom had battled breast cancer. I asked her if she had family and if they already knew. She told me that she had a 24-year-old daughter that had been really worried for her. She had recently applied for Medicaid--but it would take 45 days for her to go through the approval process. Furthermore, the area that we were located in, South Texas, is perpetually notorious for being underserved, especially in the capacity of oncology. There are so few doctors, and many left the area, that the waitlist is a long ways out. The hospital that I worked at had to even hire locums--doctors that temporarily work in the area to fill the dire need.

“How's she doing?" the patient asked me. She meant my mom. My mom was doing exceptional--she had received care back in my home state of Colorado. She had the cancer caught early because she had received her annual mammogram. "Stage 0" they had called it because it was so small. She had an estrogen-receptor-positive cancer, another good prognostic factor, that meant follow-up treatment could be a targeted hormone-receptor blocking agent.

My family had insurance, and the lump had been surgically removed with a procedure that was of the cutting-edge and best standard-of-care. The surgery had been done readily; in a short time-frame, my mom had been scheduled and brought in for treatment. Only a small scar remained. She literally had the perfect storm. I couldn't have asked for a better outcome. I looked at this patient.

The thing about health care is that often times we don't know the process of treatment until we or our family experience a medical issue first-hand. We don't see the unfairness that others may face because of their circumstances. We don't know how blessed we may be to understand the treatment process or to have access to the treatment process. I felt guilty that I knew how different things were for my mom and for this woman in front of me.

My patient had no real idea what to expect until something developed and had progressed, that was now forcing her go straight through the fire. I knew when she was asking about how my mom was doing, she wanted to know what happened. And maybe it would happen to her too. I told her my mom's story. And then I squeezed her hand, “You did so good."

“What?" she seemed taken aback by my words. I smiled, “You were so calm, and you did so good during that procedure."

She smiled back. I think I may have found some words.

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Mr. S.

When people ask me about memorable patients, I think what they intend with that question is for me to tell a story about patients that have left a positive impact on me. The ones that have driven me a certain way—changed me to be better. I think they are thinking of successful, happy, positive stories. 

 If I am being honest, when I think of memorable patients, I think difficult. They have changed me to be better,  but the memorable patients are the ones that were difficult to diagnosis, the ones that were a challenge to convince, the ones that never trust anyone, the ones that will refuse to follow your instructions or advice and were the ones that I usually didn’t have an easy time with.  Most of the time, when I was in the midst of treating them, I was dreading it. One such patient, a memorable patient, fell in the category of difficult to diagnosis. I was on the wards. He was a 65-year-old gentleman. He had presented overnight to the ED for flank pain that radiated to the groin. He had a past medical history of colon resection and now was experiencing ascites, or fluid in the belly. He was lying in bed when I first saw him, Mr. S. 

Mr. S was blunt. He didn’t mind telling you about all his issues and that included issues he had with the doctors who were treating him. We started his work-up with many of the standard tests, including a complete blood count with differential. That allowed us to look at his blood cells, and it would distinguish for us the number of each cell in his blood. His results showed severe low red blood cells—so severe that he was at the level that required a blood transfusion. His platelets were also extremely low. These are the cells that allow the healing of damaged tissue and are important when there is active bleeding because they form clots that stop the bleed. He also had a remarkably high white blood cell count. These cells are important for infection fighting. At this point in his work-up we needed to find the source of his dangerously low red blood cells and platelets, and reason for abnormally high white blood cells. 

There were no sites of active bleeding when we did a CT—no source for losing so much blood.  There was no real signs of infection, and his testing for common viruses that may be the source of a high white blood cell count, came back negative. The only remarkable aspect was enlarged lymph nodes that were seen throughout his body: neck, chest, vertebral column.  It is what we call “diffuse lymphadenopathy.” And it is common in lymphoma or cancer. 

We consulted surgery for an excisional biopsy—a procedure Mr. S was not too excited about. At this point we were draining fluid from his belly every two days because the fluid was reaccumulating that quickly and causing so much pressure that he was having difficulty breathing. He had been sore at those various sites that we had drained him from, and he would make sure I knew it every time I saw him. He would loudly grumble and grunt whenever I examined his belly, even in spots that were far from the drainage site. He would roll his eyes, when I would mention that we would need to drain his belly again. It was hard for me to see him every day and tell him that we still didn’t have a diagnosis despite the fact that we were picking and prodding him like an experimental animal. We were collecting his blood, sending his belly fluid for analysis and coming back with zero answers. Now I was suggesting another invasive procedure--the biopsy. When I thought that it was probably not going to get any worse of a situation in terms of excessive testing, we got word from surgery that they didn’t want to do an excisional biopsy due to the patient’s unstable platelets, and that we would need to consult interventional radiology to do a core biopsy instead. Core biopsies are not the most helpful in a situation like possible lymphoma. But surgery was refusing to touch Mr. S, and we needed answers, so we went ahead with the core biopsy. The frustration with Mr. S was only building. Each day that we had no diagnosis and only more procedures and tests to gain consent for, the amount of distress I felt was building too. 

It was difficult—difficult to face him. But there is one thing that I realized as I visited him. He was building his trust and confidence in me despite the fact that I had not given him one solid answer to why he was sick. I was building a relationship when I would see him and ask him how he was doing, and what I could do to make him more comfortable. One day it was to plug in his cellphone to charge because he could not reach the wall socket across the room being hooked up to several IVs. Another time, it was providing ice chips because he was NPO or “nothing by mouth” for his CT scan and was so thirsty waiting to go down for his scan (one of my least favorite things to do is place that NPO order).  

One day I tracked down the nutrition delivery to get him lime Jell-o instead of vanilla pudding. I think those circumstances allowed me to get past his frustration, and even though when I finished my time on the wards he was still in the hospital—still without a diagnosis, and status post two core biopsies that were negative—he was willing to not grumble when I examined him on our last day together. Mr. S was a difficult patient, but I didn’t want him to change. He changed me for the better being exactly who he was: memorable.

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Gray Skies.

Being on internal medicine wards means seeing patients that are severe enough to be admitted to the hospital but not to the level of needing intensive care (ICU). They are relatively stable enough. Not to say that these patients are healthy. But during my third year of medical school when I first found myself on the wards, I never saw a patient pass away. That’s pretty…lucky I would say. The odds of someone dying—on any rotation--are good odds. And I’m not a pessimist—it’s just that we see so many patients, that it is hard for me to believe that one of these patients may not be at a point where death is unavoidable. But it never happened, and I was lucky. 

When I started my fourth year of medical school, and was doing my sub internship in internal medicine, I was ready for more of what I had seen in third year. I was ready for presentations of patients, morning report, and people coming in with ailments that ran the spectrum from kidney stones to cholecystitis. I wasn’t ready for death.

One morning, I was asked to follow a patient that had been on our service for a while, but I had personally not seen before. This patient was sick. He had worsening kidney failure. The previous day, the  nephrology team had made one last ditch medicine change as an intervention before they would move onto dialysis. It was a last attempt at what had been multiple attempts to reverse this failure. On top of his dysfunctional kidneys, he had liver failure too, and was recovering from encephalopathy due to high ammonia levels—it was the reason he was admitted in the first place. 

I was apprehensive because I was already following three patients and my senior resident had asked me to take on this patient, as well as bring a third-year medical student with me to round on this patient and show him the ropes. My mind was racing as I tried to plan how I was going to manage this, and be prepared for presenting each one, along with this patient who I had never personally followed, and barely knew his history. 

We found the patient on a Bipap machine, sleeping. The nurse followed the student and I into the room. I placed my hand on the patient’s shoulder in an attempt to rouse him. He continued to snore. I rubbed the patient again, and gave him a good sternal rub; he grunted in response. I asked him if I could exam him, he grumbled in response. The nurse also attempted to rouse him from his stupor and announcing to him that I was there to exam him. She took the mask off his face and his dentures fell out, to which he finally mumbled something about a car accident. It seemed like he was having a deep dream. He seemed tired. I quickly checked his heart, lungs, abdomen and peripheral extremities. The nurse, student and I left. 

Nothing seemed out of the ordinary. I continued to round on my other patients, rushing from floor to floor. Then I got a phone call. It was my senior and I quickly answered. Her voice told me that this was not a normal phone call. Something was not ordinary. At least not anymore. The patient with the encephalopathy had become unresponsive. They were moving him to ICU. Why hadn’t I told her that he was unresponsive? I was in pure disbelief. He hadn’t been when I had seen him about half an hour ago.

The resident that was following the patient had also rounded on him this morning and he had been arousable then too. To have the patient deteriorate so quickly, and to have him to the point of unresponsiveness had me feeling sick to my stomach.  What had I missed when I had examined him this morning? He had seemed so grumpy and sleepy, heart sounds were there, and he was breathing fine…

The next morning was rainy and dark. It was a grumpy morning. Dreary I think is the right word. I opened up the EMR, glanced at the patient list for my team. The patient’s name was greyed out like the sky. He had passed away overnight.

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