I open the electronic medical record, select my patient’s name, and create a new document: “History and Physical.”
How to capture it, this woman’s history?
“This should be a straightforward admission,” the hospitalist had said earlier, as he gave me the one-liner about my new patient. For a third-year resident who had weathered several ICU rotations, caring for a patient with a case of cellulitis would be no big deal. With a couple of hours to go in my shift as cross-cover resident, it was my job to ensure the patient was stable, complete some basic orders, and let my colleagues fill in the rest of the history in the morning.
I knock on the door to room 636. My patient looks comfortable but tired—an elderly lady illuminated by the harsh overhead light as she rests beneath the thin sheets. It has been a long day for her, too. Her left hand is wrapped in clean gauze, a souvenir from the emergency department. Neatly arrayed on the table beside her—cell phone, eyeglasses, purse, and a laminated card with her medical problems, medication list, and emergency contacts. At the end of a long day, I appreciate the simplicity.
History of Present Illness: She had burned herself while cooking. She is obese, with arthritic knees, but she still prepares her own meals. Her distal extremities have been numb for years due to diabetes, and she hadn’t noticed the partial-thickness burns on her fingertips until two days later, while washing her hands. By that point, she had developed an infection: the skin pulled taught around swollen digits, the palm red and hot.
“I didn’t want to lose my fingers,” she tells me, explaining why she came to the hospital.
After examining her (faint lines on her neck and chest betraying carotid endarterectomy and coronary artery bypass; smooth concavities left behind by two amputated toes), I ask about her code status. It is a standard question I have been trained to include for all of my patients, though it still feels unnatural: If your heart were to stop, would you want chest compressions, electric shocks, a breathing machine?
A couple of hours to go in my shift. Orders to enter, a history and physical to write, a pager that will not be quiet. My pen is poised, waiting for her to answer so I can move on. She doesn’t hesitate.
“When it’s my time to go, I’m ready,” she says, closing her eyes. She shifts her head on the pillow, turns away. Suddenly, I notice that she is trying not to cry.
“My husband died in April, two months short of our 50th wedding anniversary,” she continues, her voice breaking. “I miss him terribly. So, when it’s my time to go, I’m ready.”
I look up from the notes I have been scribbling, lay my hand lightly on the blanket covering her legs. “I’m so sorry,” I say, and she thanks me, but we both know my words fall immeasurably short. I can prescribe antibiotics, or perhaps get her a cup of ice water to moisten dry lips. But I cannot make her whole again, cannot heal her infinite longing.
A few minutes later, I am back at the computer. I complete her “History of Present Illness,” writing in shorthand about her burn, her insensate fingers, chills and lack of appetite. Under “Code Status,” I indicate, “Do not resuscitate,” distilling her lifetime and her loss into a space much too small to hold them.
My shift over, I drive quickly home on the dark highway to my sleeping husband and baby daughter. When I arrive, I tiptoe into her room. I stand over her crib for a moment, listening to her hushed, rhythmic breaths, taking measure of what I have.