Monday, April 21, 2008

My Yellow Man

A friend asked why I didn't write more posts when I was doing internal medicine since I speak about it so much. Truth is, I wrote more than ever, I just couldn't post them. To me my writing seemed crass, cynical, and unfeeling. I read them and found a part of me I didn't want to see. It was uncomfortable.

My world resembled the House of God, where instead of having names my patients were diseases. I spoke of Gomers* that I always hoped the medical students would have to admit and not me. I managed to strike a deal with my senior resident to assign me the injection drug users instead of the old people with complicated (yet boring) histories who are terribly hard to turf to another service or discharge. Stepping out of my body I saw myself as someone I wouldn't want to hang out with and didn't respect. Despite my attempts to label and depersonalize my experience, there are patients that I can't forget. Like the Yellow Man.

He was transferred from a small hospital with hepatic encephalopathy, straight to the ICU. He was a deep yellow hue. His liver presumably pickled by years and years of alcohol. He was 50 and nearly died in the ICU. But not quite. He then came to my team as my patient. His belly taut with fluid, of which 6 litres had already been drained and his limbs wasting away, his cheeks sunken. My Yellow Man couldn't talk, he moaned at times, laughed eerily occasionally, slept infrequently, and constantly chewed. On the bed sheets, on my hand when I wasn't careful, on the ear of his stuffed rabbit. His eyes darting from side to side, he squirmed to get out of bed constantly and eventually had to be restrained, his breath rasping. The treatment for hepatic encephalopathy is basically diarrhea to remove the toxins affecting his brain. It sounds inhumane but we just give laxatives everyday. The nurses tired of the constant cleaning and at some point he got a rectal tube... in addition to his catheter and feeding tube.

Truth is, my Yellow Man didn't sound like a nice guy. His partner was reluctant to visit, apparently there had been repeated abuse. His kids stayed away. He had an impressive criminal record, I guess he liked starting fires. At one point I consulted the GI service. The fellow who did the assessment told me the look in his eye was "pure evil" and recommended I consult psychiatry and not give him matches. We joked about my Yellow Man, and yeah, like psychiatry wouldn't curse me for such a lame consult, he's chewing on a stuffed animal and can't even speak.

I went in every morning each day of my rotation. Talked to him as if he knew who I was. Listened to his breathing, checked his belly, made sure he was still peeing and that he hadn't pulled the tube out of his nose that was feeding him, and tried to figure out what to do. He got a lung-full of blood at one point, went back ICU, came back to me and the ICU said they wouldn't take him back. I tried to turf him back to the peripheral hospital he came from for palliation but they wouldn't bite.

We thought he was a vegetable, and a sociopathic one at that. He repeated pulled out his feeding tube and we were at a loss of how to provide nutrition. Showing no signs at all that he wanted to live and no improvement in his condition. The family member that would always visit was his 'sister', a close cousin. She would come with her daughter, stroke his head, speak to him softly, wash his face, and claim he understood it all and responded. With her he sat up and ate an apple piece by piece. I chatted with them a lot. She called me 'Shaun' and was determined to take him home and feed him freshly squeezed organic fruit juice with this new juicer she had bought. I met her on the rooftop patio once when she was on a smoke break and offered her one of the donuts I had made for my team. As she took one her eyes welled up and she hugged me. She smelt like cigarettes and pine trees.

The last day of internal medicine I was on call and my Yellow Man started having trouble breathing, his oxygen saturation plummeted, the x-ray showed an aspirational pneumonia and he became drowsy and exhausted, gasping through his mask for air. I called the family and they came... all of them. I walked into the previously empty room now filled with a dozen people. A large native family, they sang and prayed and asked if I'd like to say a few words, Dr. Shaun.

My call ended and I left. I never say goodbye to my patients. Never let them know the new team will be by tomorrow. I can't stand the discomfort of it but I wonder if they care, if just another white coat means anything to them. I heard my Yellow Man died. His life seemed unhappy, even tortured and his end was uncomfortable. And what was my part in it all? What could I say in my last few words? I said that I knew he was loved.

*Gomer (noun: "get out of my emergency room" - a patient who is frequently admitted with complicated but uninspiring and incurable conditions)