Turn It Around

Last week, I met a patient with hemophilia A, HIV, and HCV cirrhosis ("triple H," as he called it) who presented to the hospital with altered mental status and spiked a fever soon after his admission. It turned out he was encephalopathic with possible spontaneous (or secondary) bacterial peritonitis. The first morning of his stay in the hospital, he appeared to have a normal enough mental status. As such, he was not being monitored closely. When I went to see him with one of my senior residents, we found him falling asleep in the shower - at risk of falling, injuring a body part, and possibly bleeding to death (probably not, though).

I was instructed to ensure his safe return to his bed. This involved hanging out with him in the bathroom as he attempted to dry himself off in his vaguely-awake state. He plopped down on the toilet and proceeded to relieve himself in front of me as I pretended like I was used to this sort of situation. Happens all the time. I helped him put on his underwear and some pants and eventually guided him to his bed. I patted myself on the back afterward, both for tolerating the somewhat awkward circumstances and for averting what could have been a disaster.

Hardly a day later, we ended up doing a diagnostic paracentesis of the fluid in his belly - we took a sample to determine what kind of infection was responsible for his fever. Much of the diagnosis hinged on a single numerical value: the number of polymorphonucleocytes (a type of white blood cell) to be found in the fluid. If highly elevated, the value would suggest secondary bacterial peritonitis. If mildly elevated, the value would suggest spontaneous bacterial peritonitis. They sound similar enough... except secondary bacterial peritonitis is associated with a significantly increased mortality rate when compared with the latter.

Just two or three hours following the procedure, the count came back: 12,800 WBCs, 70% poly. Mildly elevated implies >250 poly count. This value was well into the thousands. I excitedly reported this result to my senior resident, only to see his face fall. "That's... really bad." And he was silent for a little while. I found myself confused. The tap was a success - we have a conclusive value, we can assign a diagnosis... aha! Secondary bacterial peritonitis. Case closed. But that's precisely the problem. The case is far from closed.

At this stage in the game, that's precisely all it is... a game. Some would argue that treating work in a hospital like a game is the only way to survive. You can't empathize with every sick patient in the hospital, nor can you console every family member of every dying patient. Who has the time? Who has the energy? Yet there are others who would argue that you can't afford not to empathize with the sick people you are treating. I learned more from observing my resident's reaction to the bad news I delivered than I did from most of these last three years.

During rounds last week, he shared a story of a patient he saw while in medical school. This patient of his was a perfect example of everything that can go wrong in a hospital, resulting in completely preventable bilateral below-the-knee amputations. The only success he describes in his story is her eventual regaining of the ability to stand with prosthetic support. At the time, I thought to myself, "Big deal." The resident earnestly encouraged us to find similar stories of our own, to hold onto them, and to always remember why we ever decided we wanted to spend our lives helping people in the first place. I thought to myself, "Lame."

This entry is not about my finding a similar story for myself. It is about my realizing how easy it is to lose your humanity when working in a hospital. You can find yourself congratulating yourself for helping a patient in the most menial and basic of ways... and a day later find yourself completely ignoring the consequences and implications of condemning a man to death.

It's more than a game. It's about surrounding yourself with the sufferings of real people... and learning to embrace it. And so the questions I now face are numerous. Am I ready for this kind of commitment? Will I ever grow to love my job? How much more of this can I possibly endure? When will I finally start to feel like a doctor?

Today I left the hospital at close to 7PM. It was not a call day. And I had been at the hospital since 6AM. I spent most of my day on the phone, trying to expedite and facilitate the various processes that need to happen in order for a patient to receive proper care: labs to be drawn, imaging studies to be performed, reports to be uploaded, conversations to be had. There are precious few opportunities for any one individual who works in a hospital to be involved in direct interaction with the patient. It is one massive, orchestrated, yet often dysfunctional team process. But it works. Most of the time. And it needs workers to function.

All this time, I had been looking for something meaningful to do with my life, preferably unrelated to medicine. I found comfort in excuses and turned my nose up at what truly is a privilege: the opportunity to be in medical school, the opportunity to become a doctor. It's taken me a long and difficult three years to realize that I might actually need to work to achieve my goals... to pursue happiness and to find contentment.

I'm not there yet. But I will be someday.

Let's turn it around.