Vacation! I do love that word. About two months before Thanksgiving, I made a decision to take the whole week of Thanksgiving off. I treated myself to two days at home, puttering in the garden, clean-up chores, reading a mystery novel, getting some exercise and relaxing. On Thanksgiving eve, I was busy preparing several dishes for the holiday when my pager went off to call a Family Health Center number at about 6:30 p.m. It was Ginny and she had some bad news. One of my patients, Mr. D, a Dominican man in his 70s who had been in the ICU, was about to be removed from the ventilator following a family decision. I had been aware of his ICU stay for more than a week from a huge upper GI hemorrhage from varicose veins in his esophagus. I sighed and wrestled with the mixture of feelings: sad for him, guilt for not being there for the last week, irritation that I had to go to work. But I resolved to do what was right.
It has been seven years since I have done hospital medicine. It’s hard to believe that it has been so long. With the increasing degree of electronic connectedness, I now follow my inpatients via the computer. Email brings notes of emergency room visits with chief complaints, CT results, admission announcements with admitting diagnoses and discharge information. When bad things happen such as this, I regularly open Meditech and flip through ICU notes, labs, x-rays, etc. Periodically I will call residents, patient families and, when I think it is important, I make a point of going to the bedside. My worry about Mr. D had hung like a sometimes conscious and sometimes subconscious cloud, aware that he was dying and following his course: coma, pneumothorax, fever, transfusions, aspiration pneumonia, emergency TIPS procedure to stem the hemorrhage. Bad, all bad.
I met Mr. D about seven years ago. His wife had been my patient for years and she asked me to take him on. Several days before his first visit, she expressed concern about his drinking, stating that he could plow through a case of beer in an evening while watching his beloved Red Sox. When I met him, I eventually asked about drinking with his wife sitting beside him. He looked me straight in the eye and quite believably said: “two beers.” I shot a look at his wife who rolled her eyes and shook her head. I couldn’t help it, I laughed out loud. That was the start of a “beautiful relationship.”
We tackled diabetes, chronic arthritic pain and depression over the death of his brother back in the Dominican. He cut back on his drinking with the diabetes but it wasn’t until he had a GI bleed and we learned of the smoldering cirrhosis did he quit drinking for good. For eight months of the year, every visit included some discussion about the Sox, whom we both loved. We relished discussing the World Series wins, Big Papi, Pedro and Manny. More than once, I fantasized about taking him to a game, something that he had never done and never could afford.
Despite his shortcoming with alcohol, Mr. D always worked hard. Until his late 60s, he worked in an industrial laundry, lugging 50- to 100-pound bags of laundry over and over eight hours a day. His back and his knees hurt all the time. More than once I thought, “Who wouldn’t drink with that kind of life?” He was so happy when he retired.
Mr. D’s wife has a baffling constellation of connective tissue disorders without a diagnosis. She’s been blinded by chronic uveitis, had a stroke in her 40s and developed bilateral kidney obstruction causing mild chronic renal failure. No one knows what to call her disease. For years, he and his wife had fought hard to bring their daughter and grandson to this country and were finally successful about four years ago. I followed her during her second pregnancy, with overt diabetes diagnosed early on leading to a Memorial transfer. I also take care of her son, a wonderful young man who looks and acts older than his 13 years, and now his baby brother, whom he adores.
On my way to the hospital, I tried to get a Spanish interpreter, knowing I wouldn’t be able to convey what I wanted to say. I failed and hoped that the team had one there, but they did not. As the doors to the ICU wooshed open, I saw his daughter. She sobbed on my shoulder. I entered the room and there he lay surrounded by family and friends, many unknown to me. He was still breathing and had a pulse, but death was imminent. I shook hands with his grandson and then turned to his wife who sobbed for many minutes on my shoulder. I said the words I know: “Lo siento mucho.” I’m so sorry. “No va a sufrir más.” He will not suffer any more. “Él era un hombre bueno.” He was a good man.
After he died, a physician assistant and a family medicine resident working in the ICU came in to pronounce him. The PA seemed to take forever listening to his heart and lungs. They asked me to ask in Spanish if they wanted an autopsy. I recognized the rituals of the Unit but no longer felt like a member of this club. At one point, his wife had a full blown panic attack and I was afraid that it was a stroke or heart attack, but followed my instincts and whispered for her to calm down, massaging her neck and shoulders. I went to the nurses’ station to get a prescription pad to write her for a few low dose lorazepams. I couldn’t have one, they told me! I smiled, shook my head and accepted that I’d have to fax it electronically when I got home.