22 April 2011

A year for patients

For K and K

The first patient who died and the first newborn I took care of in the nursery – have the same name.
K--- .
I wish I could write it. Suffice it to say, it’s a beautiful name and an uncommon one.
The first patient who died, the first K, was 29, with metastatic cancer. Latina.
The first newborn in the nursery, the first birth after K and a string of other deaths, was 6 hours old when I met her. Half Japanese, half Turkish.
And they have the same name with the same spelling, and, most likely, the same black hair.

Born thirty years apart.

This year, I’ve kept track of all my patients who have been born and who have died.


For births, these were only the ones where I performed the birth, where my hands were on the body that became a child. I didn’t include the ones where I just watched. These were also the ones in the newborn nursery where I took care of them, I examined them moments after birth.

For deaths, these were the ones who were my patients. These were the ones whose families I had met and spoken with. And these were the ones who died in the hospital – that’s how I knew. I don’t count the ones who were discharged and who have likely died this year, as well. I don’t know for sure. I don’t count them. I don’t count the ones on my team who weren't my patients.

These patients are represented by beads on a thin, silver, malleable silver wire. Blue are born. White have died. It’s a small string, now, with knots and twisting between each bead. I keep it curled up in a box, and I plan to maintain it throughout my career. This small remembrance, this small tribute. Each time, I take the moment to think about the person, the patient, as I add them.
This started one week into my third year, the first time I was on labor and delivery. The last bead was a few months ago. None of the patients I directly took care of, on surgery, died. One is now in hospice, though, and has declined further treatments.
Since I’m going into internal medicine, and maybe I’ll do another labor and delivery elective – but likely not – I won’t have new blue beads in the future. Maybe I can count babies born to my patients. I have to find some way to balance the white.


The first K I saw every day for two weeks, on my in-patient internal medicine rotation. It was July. She never complained of anything. She was wasting away. Everyone who walked into the room knew she was dying. And that it would be soon. Chemo and cancer made her look like that, made her so sick.
She wanted to keep going with treatments.
She wanted to see her three children again.
In the end, she couldn’t do both. And she died in the hospital. And the last days, she was unconscious. When I saw her, she knew everything.
Her last days, when she died, I wasn’t there.
I heard about it after. I hadn’t seen her in a week, at that point.
This is when I learned, first, to be afraid, to keep checking, to see people when they were in the hospital, to try to find out when they were there again.


K wasn’t the one who first scared me into this.
It was another patient – and he isn’t counted, because he didn’t die in the hospital. He likely died this year. But he likely died at home. It was a Friday. My patients were K, Mr L, and a third one, young, new diagnosis of a very serious, chronic illness. After rounds, my senior resident commented that Mr L probably wouldn’t be alive on Monday. It was like I had been struck – I knew he was sick. I’d never heard anyone prognosticate like that. I asked the resident, later, how he dealt with the death of patients. He said, a little surprised, “…I don’t think about it.”
I had class that afternoon, briefly, but I ran back to the hospital afterward. I had to know who my patients were – I had to know them as something, someone else than the sick and dying person I’d never seen out of bed. (Over the year, this has become much more natural and a regular part of my day – until surgery, when doing this would mean I was at the hospital more than 15 hours per day, and, after getting up at 4, I wanted to go home).

I went first to Mr L’s room – and my heart stopped when I saw it was empty. Frantically looking for his nurse, I was finally told that Mr L, per his wishes, had gone home. He would stay there. I was relieved, at least, that he would get what he wanted; I still didn’t know if he would be alive. (I didn’t count him).

Next, I went to K’s room. I was afraid when I saw the sign on her door “no visitors per patient request.” It was the first time the sign was there. So, now, again, besides my daily abdominal exam, cursory heart/lungs/edema/mental status, check of lab values and recommendations for more platelets – I didn’t go.

I did go see the third patient – the one who is and will be sick, but chronically. I stayed with her and her mother for over an hour. There was something vibrant, then, about that day.

The resident said, offhand, that I didn’t need to follow K anymore – we didn’t even need to see her on rounds, not really. Nothing was changing. There was nothing to do.

The second K.
The second K was sick, for a few days. My formal presentation for that rotation was on the reasons she might be sick. She got better. I spoke with her parents several times, got to know them a bit. I met her mother’s friend and her mother’s mother, tiny and not-English-speaking.
I saw them again in clinic, the next week, with the intern who is their new pediatrician. They were more relaxed, there. Nervous, older, first-time parents.

The first K and the second K.
It’s an uncommon, beautiful name.
The unbelievable odds of having two patients with this name, of the not-so-many on my wire (I haven’t had any others with this name. I’ve had, and seen on teams, close to one thousand patients this year. More? More. )

I know exactly where each K is on the silver wire.

The first K had only boys (three) . If she’d had a girl, I doubt she would have named her after herself. But it’s a beautiful name. Maybe someone in her family will name a child K – in memoriam, in memory, in homage. One of her friends, maybe. A sister. It’s not a completely unlikely thing to happen. Especially for someone who died so young. The first time she had cancer, she was 26. They thought it went away. The second time – same cancer, now everywhere – she was 29.

I wanted to read the obituary. I wanted a small idea of who she had been in life – I didn’t want to remember her (as I picture her now) as wasted away,sinking back into a hospital bed, clearly dying. I never met any of her family. I know they came. She was beautiful. Vivacious. Loud, it looked like. Bold. Extroverted. Loved.


I was invited to a patient’s wedding this year – I didn’t go, because I didn’t get to speak to her right before she left. I was hesitating (I don’t think I would – hesitate – now). I sent a card, though. A patient brought in his daughter to meet me – he’d shown me her photos, before. Other patients kept me updated on their children’s plans and relationships. Where they’re traveling. How another patient’s son was doing in school – I met him too. Patients’ children and parents and spouses – I met lots of those. Often, I could name them before I met them – I’d heard the stories. And sometimes they already knew who I was. The patients I joked with – we ended up making fun of each other. The patients who broke down and cried. The real reasons they were there. The patients who got better, a little bit, by talking about it. The patient who is (I hope!) getting a day job, after his night job, which will help with his anxiety and his insomnia…I think, too, about the ones who were “lost-to-follow-up” – the ones I didn’t see again, or who didn’t make the next appointment. And I don’t do enough to follow-up with all of them. There is so much more I could do that I – don’t.

Patients I’d see almost every day for weeks (in the hospital that long). The patient I saw one time in clinic – and he left, angry. Marginally housed. I couldn’t do anything for that.  And then I saw he was in the ICU. I saw him there. I read the chart. I checked the notes and labs and radiology reports. When he came back to clinic – he made it through that, miraculously with how sick he was – he mentioned to me what had happened and how miraculous it all was. I told him I knew, because I had been there. There’s the patient who deeply disturbed me. We (the preceptor and I) almost hoped one of the drug tests was positive, it would explain things a bit more, his affect, something. . . the tests were all negative. I haven’t forgotten him either.
I can picture the ones who died – most of them, some of them. I can picture the ones who were born – most of them, some of them.
The morning after the first baby I helped be born, after I’d been working for about 26 hours, I went to sit and think about him, on a beautiful overlook. Softly, ‘Happy Birthday’ to him – even though we didn’t know, yet, what his name was.


The angry patients, the happy ones, the ones who are frustrating, the ones who are frustrated.

This year was one of the harder and better ones. This year. The third year, the first year of the rest of my (medical) career – the first one that is spent, entirely, in the hospital and in clinics. (years leading up to this, actively working toward a career in medicine? 9. Years since I’ve been thinking about going into medicine? 16) . Of 48 weeks of work (and four of vacation), two weeks were spent in the classroom and in lecture. Two. And counting the weekends and nights we worked and the 60-80++ hour weeks – that’s still more days than you’d usually consider in 46 weeks.

And this is what it means, to be a doctor.
This is what it means.
The rest is a lot, a lot, a lot of learning, and a lot of practice, and a lot more terrible and wonderful things, and a lot more responsibility. That will happen, that’s ahead and on the way.

A friend asked me recently if doctors think about their patients, outside of the office.
Is it possible not to?
I’ve learned, this year, I’ve seen so many doctors go above and beyond what I ever knew for their patients. It’s an incredible privilege – all of this. And the conception of the third year, the necessity to be a part of so many specialties at shifting times, means learning about what it means to be a physician more than what it means to be a particular type of doctor. There are qualities of physicians that transcend their particular work, and those are the ones I want to be, in whatever I do.

You learn how to balance things. Each birth and death since the first ones has meant something to me, has had its own space – but not in the same way. You learn to incorporate things together. An amalgamation. All of these matter, each has to matter every time, but it can’t overshadow everything else, it can’t overwhelm the space of a day or an hour.

But you remember. You worry about the biopsy. You wonder about the labs. It isn’t just that.
If a patient gets sicker – but there are so many kinds of sicker.
If a patient gets better – but there are so many kinds of better. All of them matter. We know that.

This is what it means.

For the first K and the second K.
The first K and the second K.
If there is one thing about this year that is right, it’s that.

Forget you?



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