The Wonderful Mr. W

            When I was assigned on my first day of wards to follow Mr. W, I was skeptical. As I write this, I recall thinking about how much I already knew about pleural effusions.  I was ready to discuss the factors in determining transudative versus exudative effusions by Light’s Criteria.  I could discuss with ease the finer points of whisper pectoriloqy and tactile fremitus.  To be honest, chylothorax was a bit new to me, but the uptodate app on my phone had me cued in to the basics in a few moments after the assignment.  I supposed that the ascities secondary to cirrhosis was useful review, even if I had already hit the textbooks scouring for details on hepatic dysfunction and failure the day before my start on the wards.

            On paper, Mr. W was the poster child for the kind of person the radio talk show pundits bemoan are the reason for our healthcare system’s failures.  Mr. W had a history of polysubstance abuse, with chronic alcohol use being the primary culprit for his hepatic cirrhosis.  The medical record shows that there were early warning signs, but Mr. W failed to heed the advice of his providers along the way, or so the paperwork would have you believe.   It would be easy to dismiss this man before walking into the room.

            Perhaps it was my experience as a paramedic, or maybe it was simply my joy to finally be out of the classroom and on the wards, but I walked into the room for the first time with a smile and introduced myself.  In life, first impressions matter.  This is true, but in a different way in medicine.  Immediately, I noticed that Mr. W was sitting up in bed, mildly short of breath, had a distended abdomen, and slightly icteric sclerae.  However, it was his smile that caught my attention.  Mr. W’s smile was immediately disarming.  Over the course of two weeks, I learned to lean on that smile to guide his treatment. 

            To be sure, I was able to assess the basic signs about which we were taught.  I knew to check for accessory muscle use to determine work of breathing.  I could gauge if he was more pale or less from one day to the next, which was no easy task considering the fact that liver cirrhosis had turned his skin slightly yellow.  And yet, it was his smile that spoke volumes about his overall condition. 

            Even in the face of serious illness, he would smile as though excited to see an old friend every time a member of the team walked into the room.  When some of my classmates came around during PD rounds, he shook everyone’s hands, smiled, and listened attentively as the PD attending walked us through physical diagnosis.  When his ascities got so bad that his bulging abdomen pushed up on his lungs, making it harder to breath, or when the effusion got sufficiently bad that his lungs were flooded to the point of collapse, it was not his breathing or sats that told the story.  The tools and machines confirmed what his smile already told me, something was terribly wrong.

            When things got bad, his smile would turn a little wry.  He was still clearly happy to see us, but that joy that seemed to be intrinsic to his nature was muted.  There was something a little less active, less mischievous, less lively about his smile during those days that he was not feeling so well.  During his course in our care, there were good days and bad ones.  We had to stab him with unreasonably large needles in his abdomen and sometimes his chest to draw off fluid from his lungs and abdomen.  He lived with constant pain that would fluctuate, and all our efforts to help made things better in some ways, but worse in others. 

            Over time, that initial impression that came from the cold words on his paperwork took on different meaning.  The initial impression of a man whose bad decisions led to a bad place seemed to not do justice to Mr.W.  Over the course of nearly three weeks, he seemed more like a man who loved life.  His joy in the face of serious illness was infective.  He barely spoke English, but his attitude was so lively that I would want to spend time in his room just talking to him; and we would laugh.

            And then there was a turn.  He got very sick, very fast.  I worried.  In general, I don’t spend a whole lot of time worrying or thinking about the patients I treat.  At the end of the day, I get to go home, but all day I worried.  There was a problem at dialysis, and I happened to be on the floor.  Many things happened really quickly.  To some degree, I switched to autopilot.  As a student, there is not much that I can do.  Still, I knew what needed to be done and anticipated how I could be helpful.  I pulled up his record on Sorian so that the closest computer was up and available.  The attending drew a blood gas, so I wrote an order for an ABG, had the resident sign it, and ran to the floor secretary to put the order in and get the istat person to the floor.  On my way back, I grabbed an extra ABG kit in case the attending missed the first shot and a portable O2 bottle because we were going to have to transfer him to the ICU.  All of these things would have been done without me, but the act of doing made me feel useful and took my mind off the worry.

            It has been almost a week since we transferred Mr. W to the ICU.  I went to see him in the unit.  His eyes were fixed forward.  They barely twitched when I called his name.  There was no smile.  His face was nearly blank.  I like to think that the corners of his lips may have turned up a little when I asked, “you don’t normally watch this show, don’t you usually prefer the talk shows?”  It was probably wishful thinking as I looked up at the monitor.  I think I mentally reviewed his vitals a dozen times before I gave up on trying to understand what was printed clear as day in front of me.  From an intellectual standpoint, I could probably have explained what was going on physiologically, but emotionally I simply could not make sense of it. 

            As I write this I have to study for my shelf exam, then I take the exam itself, and finally I have to move on to deal with my own life’s issues.  Up until that moment, I was so exited to be done with the wards on medicine.  So much of the difficulties in this mad house seem unnecessary and aggravating.  The EMR alone was like a perpetual foe that thwarted my best efforts at every turn.  And yet, through all the frustrations, Mr. W’s smile made my time here so much better.  There was something about him and his smile that made me want to come back every morning, even though there were times when I truly hated having to be in this old building.

            With my left hand curled into his hand and my right hand on his shoulder I leaned in and spoke the last words he would hear from me.  I am so sorry that we couldn’t do more for him.  I am so heartbroken about the loss of that smile and the blank look on his face as I stood there.  I feel as though a star in the sky suddenly went dark.  I have no explanation, no words, no way to adequately express the way I feel.  All I could do was cry.