Abstract
This is a piece from the annual Yale Internal Medicine Residency Program's Writers' Workshop, which began in 2003. Abraham Verghese and Richard Selzer, among the best known physician-writers in the United States, have served as workshop leaders, teaching the craft of writing to more than 35 residents. In designing the workshop, Anna B. Reisman, assistant professor in the Department of Internal Medicine at the Yale University School of Medicine and VA Connecticut Health Care System, and Dr. Asghar Rastegar had the goal of making participants better physicians by providing a creative outlet for reflection.The stories and essays written by the Writers' Workshop participants present a range of experiences, real and imagined, and take readers deep into the minds of young doctors trying to make sense of what they do.
Essay
He lies there, without a word. Mr. Torres, a once energetic, silver-haired man who laughed when he admitted to smoking too much, lies motionless in his hospital bed. He is surrounded by humming machines supposedly supporting every need. I am not at all sure they are helping him.
Already he is swollen and bloated, his arms and legs disfigured after weeks of fighting infection. His leaky vessels are too weak to hold the liter after liter of saline forced in, and now the pounds of fluid are simply oozing out of his skin in sticky yellow droplets.
He has not been out of bed in two months. He has tubes in his trachea, stomach, artery, penis, rectum, and two that end in a large vein just above the entrance to his heart. Every morning at 6 a.m. he is turned, jostled, tugged, and positioned with a hard X-ray board beneath his back so I can stare at the progress of the fluffy white villain invading his lungs. The infection is eating holes in his lungs, and the bed is eating holes in his heels.
He is bruised, bandaged, cut, blistered, and ulcerated, but his fingertips bother me the most. They preserve an individuality in the midst of illness that has uprooted him from home and placed him in a standard issue hospital gown. A plumber, his hands were his livelihood. They hefted metal and cranked wrenches. They also held his daughter's hand as she walked down the aisle. To the right of the ventilator is a picture of him beaming at her wedding, his hands joining her to her husband. Now his hands rest bloated and shiny at his sides, his fingers a bloody pulp, bits of old cotton stuck to the ends. Every hour, a needle punctures his finger, the tip squeezed until it releases a drop of blood, ultimately revealing his blood sugar concentration. There is an order to do this to him, and I have signed it. I can stand in my white coat and speak confidently about the Journal article that says we should do this; the article that proves tight blood sugar control improves mortality. But all the pricking and squeezing is absurd, for he is beyond tight blood sugar control. Each morning on rounds when we pass his glass-enclosed room and nod our heads, agreeing that the insulin should be raised just a bit, I silently pray that he not feel the stick inflicted every hour. It seems too unfair to prick a man dying, a man too weak to resist.
In addition to the blood sugar, I am monitoring blood pressure in two locations, heart rate, and breaths per minute. Every day I recite his sodium and potassium and check the computer to see if any of the 20 bottles of his blood incubating in the laboratory have grown any new organisms that could be battled with more fluid and antibiotics. I think about him constantly, count his drops of urine, carry 10 index cards with tiny black numbers describing him, awake knowing I have been talking about him in my sleep. I know the condition of his organs, a strange and intimate knowledge that gives the illusion of knowing the man behind the numbers. However, I know only the man reflected in his wife's and daughter's concern and the few pictures that attempt to anchor him beyond this life of tubes, beeping, and pricking. The pictures reveal a man nothing like he is now, too tired to speak, exhausted after turning his head to stare into his wife's eyes.
She shudders when she looks in to those blank eyes. It took a week for her to build enough courage to reach his bedside. The first few days she was so overwhelmed she could walk only halfway down the hall to his bed where I would find her, clutching the railing, lost in her fear. Now, with stooped shoulders and puffy eyes, she stands beside him. I am amazed at her courage to come into this room and touch his swollen hand, staining her sleeve with the yellow ooze. I don't know how she can come into this room. I can only come in when I force myself and don't look too closely. I hate myself for the helplessness I feel looking at him. I know I shouldn't have such feelings. I am the doctor. I am supposed to do something, anything. I am supposed to be realistic and honest but still impart hope. At the very least, I am supposed to do no harm. I know we are losing, and I fear I am betraying him.
I wish I could say his eyes sparkled when he saw his wife, that there was some recognition of the 45 years and the three children. No. His eyes remain faded, sunken, and focused far beyond the ceiling. It's awful to see him just staring there, his daughter tells me. I nod. What should I do, I wonder, use an extra pillow so he can stare at the wall? I touch her shoulder, and she leaves, eyes glistening.
Sometimes I sit with him when I write my notes. I am not sure if he can hear me, despite the amplifying earphones we have ordered specially for him. Occasionally, he turns his face toward mine. Once, when I was poised above his head, ready to plunge a needle in his neck, I felt him move under the blue sterile drapes covering his face. I lifted the cover to find him shaking his head — no. I reached for the amplifier, dirtying my gloves. Did he understand that he needed this line for the fluids and antibiotics? Or was he asking me to stop the pricking, oozing, and jostling? I summoned his family and watched his wife ask him about the central line. He nodded. She asked again. He nodded again — go ahead. I have never been sure if perhaps he just couldn't bear to give up in front of his wife, knowing it would hurt her to live without him. I fear I let him down at a time when I could have offered relief and comfort instead of another needle in his neck.
Several days later, his suffering was finally over, new white sheets crisp on his empty bed. That day I thought I saw his wife's shoulders lift just an inch. Why do we know so little about when to let it end? I still talk about him in my sleep.