It’s the early morning hours on the Bigelow, one of the general inpatient medical services at Massachusetts General Hospital, and it’s finally getting quiet. In the wee hours of the night, I check in on the 20 or so patients under my care, poking my head in the door, turning off a light here and there. Most of them are sleeping; some are watching infomercials. Hours earlier, most of the TV sets were tuned to the Red Sox game. My first night on call as an intern is coming to an end.
I check on a few “active” patients several times over the late-night and early-morning hours. One patient, Mr. J, a transfer from an intensive care unit, has a low platelet count. An astute nurse came to me earlier in the evening to mention a rash on his backside. When I go to inspect him, though, it looks more like petechiae. I recheck his last labs, and his platelets are 26,000. Earlier in the day, when the team decided during morning rounds on transfusion parameters, we set it at 10,000.
The patient also has a bag draining fluid from a previous paracentesis, in which a needle is inserted into the abdominal cavity to drain fluid. Now there is less drainage and more blood. His nurse tells me he is guaiac-positive, so he is bleeding from somewhere in his gastrointestinal tract. I page the senior resident who is assigned the role of “teaching senior” tonight. She’s a very thoughtful, very kind doctor, and when I explain the laboratory and physical findings, she comes by to examine Mr. J with me. On further questioning, Mr. J says that when he blew his nose today, he had blood on his tissue. We explain to him our concern for his low platelets and the need to give him more. He asks us a few questions about the logistics of the transfusion and then changes the subject.
“I have this question,” he says. “My son is getting married at the end of next month. Do you think I might be able to make his wedding? You know, only if I am well enough.” He seems close to crying. His expression is serious; he’s a little tremulous; and he looks intently at the two of us. The senior resident takes the lead and explains to him that many things can happen over the course of this month. He is very sick, and we just can’t say at this point. I can tell he knew this answer already in his heart before he asked the question.
After his transfusion, I stop by to see how he is doing. He asks me when Aug. 1 is—he’s looking at a calendar on the wall. I flip through—it’s next Wednesday, I tell him. “I’m trying to figure out how long I have until my son’s wedding. They found this great place in Maine, just on the internet, and they got two-night stays booked at the hotel and….” He goes on to tell me how happy he is for his son and how much he likes his future daughter-in-law (she’s quiet and sweet, but she speaks her mind, and he likes that) and how he is hoping for some grandkids. I say goodnight and wish him a good rest, since it’s been a long day for him.
I find myself thinking how being a doctor is so intimate. I’ve just met Mr. J, and he’s telling me about his family and his hopes and his fears. And this kind of intimacy is the rule, not the exception.
Earlier in the evening, I admitted a patient with a catastrophic subdural hemorrhage who, after lengthy discussions with his family, was made “CMO,” or comfort measures only, meaning that the family wanted no medical interventions to prolong his life but those that would make his passing humane.
Now, I sit down at the bedside with his wife and son-in-law and go over the measures that I will take over the course of the night to make him as comfortable as possible. They tell me his story, and at first it is about the events leading up to his hospitalization: a typical evening at home, dinner with a bowl of ice cream, then finding him unresponsive in bed in the morning. “It all happened so quickly,” his wife tells me. “I keep trying to think, was there something he did, that I did? What could we have done differently?” I answer their questions as best I can. They also tell me that they decided not to pursue aggressive treatment because Mr. K had made his wishes expressly clear on several occasions.
As our conversation comes to an end, I write down the number to call to reach the unit and my name in case they want to page me directly anytime for any reason. I reassure them that we will be watching Mr. K and taking good care of him overnight. Then his wife tells me how they have been together for almost 33 years. She tells me how they met, how she fell for him, about their travels together. “We had our small arguments,” she says, “little stuff. But he took care of me, and I took care of him.”
She tells me about her recent diagnosis of breast cancer, the mastectomy, how she needs to get fitted for a prosthesis. She starts getting somewhat agitated. I put my hand on her shoulder, and she looks at me with eyes filled to the brim. She wants to go home where the rest of the family is waiting. The grandkids are coming home early from camp. We stand up, and she walks to the side of the bed. She kisses her hand and presses it to his forehead, and they leave for the evening.
Erica Seiguer Shenoy, MD–PhD ’07, is an intern in internal medicine at Massachusetts General Hospital.
