On the eleventh floor of the safety net hospital a frail man is admitted for tertiary care. His left third digit is mottled and purple and dribbling golden sticky fluid and too painful to touch or bend. The nursing home says he could walk and talk and provide consent before he left their hands and came into ours but we wonder. He mutters words we can scarcely hear. A tube protrudes from his chest, secured with tape, unused since last November, the most recent time he allowed his doctors to perform hemodialysis – the work of filtering his blood that his kidneys gave up years ago. Somehow he has remained coherent for four months without this critical treatment and just ten percent of his kidney function.
Remembering my teachers I close the EMR and, without further influence from the words of others, enter to see my patient.
He won’t respond to his name and only intermittently makes eye contact. I immediately regret habitually muting the television on arriving at the bedside. The channel rests on calming nature scenes, formerly accompanied by soft piano, which I would much prefer to the silence of his indifference. This one sided interaction is uncomfortable.
He swears at me when I examine his finger. I am pleased he has acknowledged me, albeit with choice four letter words. Response to painful stimuli, check. Concentrating on the routine of the physical exam, piece by piece, head to toe, allows me to avoid my own discomfort and horror as my delirious patient pulls pieces of his hair out of his scalp, then digs into his nostrils, then tastes his fingertips. I push away my reflexive disgust and ask myself what my responsibility to this patient is. I ask myself how I would be acting right now if one of his four children, with whom he is apparently close, were here. I ask myself how I would be acting if this patient, this former veterinarian, was coherent and oriented. I steel my stomach, don a pair of gloves, and tenderly wrap his hands. I ask for restraints as his nose begins to bleed from the picking and digging.
On my way home, I call my mom. She answers after a single ring, wondering why I’m calling so late (or early?). My voice cracks as I tell her, urgently, “I will never let you go to the hospital without me knowing.” She affirms, half-asleep, asks: “Is that all? Are you sure you’re okay?” I assure her, yes, I am, I will be, as I silently promise myself to admit my mom not to a nursing home but to my own multigenerational household. Still half-asleep, she asks again, “Is that all? Are you sure you’re okay? I’m sorry honey, I’m just so tired.” I assure her again, yes, I am, I will be. After I hang up, I give my nervous system the gift of a long exhale.
4/2/23 ~ MH IM rotation
