For doctors in training, out-of-hospital medical encounters can be the most memorable
A University of Pennsylvania surgical resident and a fourth-year medical student at Penn describe how, when they expected it least, they gained major insights into what it means to be a doctor.
Editor's note: Medical students and residents are famous for hardly ever leaving the hospital. They may see hundreds of patients every week at the bedside or in clinic. Yet, sometimes, it's an unexpected encounter outside the hospital that can prompt a harried, sleep-deprived mind toward new insights into the real reasons for the hard work. Jason Han, a resident in cardiothoracic surgery at the Perelman School of Medicine at the University of Pennsylvania, and Christopher Magoon, a fourth-year Penn medical student currently on a Fulbright grant studying public health and Mandarin in China, share two memorable off-duty encounters.
Jason’s story: ‘We have to keep trying’
One wintry evening a few days before Christmas, I was rushing down a street in Center City when a young, disheveled man sought my attention. He was gesturing toward his left hand, and I assumed he was asking for change. Occupied in thought and eager to reach home, I briefly feigned acknowledgement, uttered an apology, and walked on.
A few paces later, my brain caught up with what I had just seen and heard. Halting my steps, I replayed his words in my mind:
"Do you have a tissue? My hand is bleeding."
He had not asked for money. He needed medical attention. I turned around and rushed back to him.
"Excuse me," I said when I walked back to him. "I'm not sure if I heard you correctly the first time. Did you say that you were bleeding?"
He nodded and showed me his left hand. What I had mistaken as dirt was in fact an impressive trail of stitches holding together a recent wound without a dressing to protect it.
Even under a dim street lamp, his wound was a textbook image of infection, with the classic signs every first-year medical student learns: rubor (redness), calor (heat), tumor (swelling), and dolor (pain).
"How did you get this wound? When did it start looking like this?"
He told me that he had been injecting heroin in his left hand. Over time, the site had developed a pocket of infection. Though he recently stopped using drugs, with support from friends, he had to go to the emergency room a few days ago when his body's efforts to contain the infection began to fail and he became violently ill – a condition we refer to as sepsis. His abscess appeared to have been drained and treated with an IV.
As if he noticed the concerned look on my face as he told his story, he stopped and looked up at me curiously. "Should I be concerned?"
"I'm afraid your infection is coming back. Were you prescribed antibiotics? What happened to your bandages?"
"They did give me a prescription for antibiotics and told me I needed to take it, but I can't seem to find it. The dressing fell off by accident. Do you think I need to go back? I feel fine." He continued to pick at the wound with his dirty right hand.
"Stay here for a moment, I'll be right back." I dashed over to a nearby CVS for supplies, and came back to clean and wrap his hand. As I worked and we talked, I realized two things. First, he wanted to get better – the fact he was off heroin made that much clear — but he didn't know how. Second, whatever he'd been told at the hospital about caring for this serious wound was lost entirely in the translation to his daily reality.
As a cardiac surgery resident, I often meet patients who are in drug addiction. Bacteria introduced to the bloodstream via intravenous drugs can ravage the heart valves – a condition called endocarditis. It is a life-threatening condition that can ultimately require open heart surgery to take out the infected valve and replace it with an artificial one.
We give patients a stern talking to about avoiding IV drug use and other risk factors. Sometimes we counsel them on antibiotics just as a precaution.
"You know," we will say, "surgery doesn't prevent recurrence. This infection nearly killed you this time. Next time, it may claim your life."
We comfort ourselves believing we were as clear as could be.
Advances in technology don't help us reach our patients where they live. Poverty, addiction, lack of social support, and poor health literacy can entrap them in cycles of illness. No matter how many high-tech medical interventions we give them, none of it matters unless we also can give them the tools they need to be healthy.
The man who reached out to me for help is a testament to the fact that unless we move forward together, there is no true progress in medicine. We may struggle to find the right words to simplify our prescriptions or feel too constrained by the demands on our limited time to connect our patients with the social and financial help they need.
But we have to keep trying. We have to meet our patients where they are, no matter where that may take us.
Christopher’s turn: Planning a death with dignity
Dressed in jeans and a sweater — white coat hanging off-duty at home — I met up with an old friend on a sunny afternoon in Philadelphia last summer.
I had no idea that on this break from the hospital, I would end up having my most gratifying medical discussion yet.
We talked about his career changes and my progress through medical school. He mentioned that he was in town because his mom was sick — quite sick — with an uncommon and incurable neurological disorder. As he described coming home to be with her, his spine slumped, his speech slowed, and for a moment his eyes looked full, as if he might cry.
My friend is a high-achieving lawyer, Mandarin speaker, and entrepreneur with multiple Ivy League degrees. But there was nothing in his infinite stores of energy and talent that could help his mother. He described the vibrant woman who raised him, and the woman she had become, unable to walk, feed herself, or, toughest of all, think clearly.
He was ladened with a thick envelope from her lawyer's office, full of forms with boxes he was supposed to check off to select the details of how his mother's last days might unfold.
My friend is an accomplished researcher, but he struggled to find reliable information to plan for his mother's decline. As a fourth-year medical student, I had completed my clinical rotations. These experiences piqued an interest in end-of-life issues, and I had seen many families face these kinds of questions. He showed me a sampling of the forms, highlighting his points of confusion. Like so many people in his position, he struggled with how "aggressive" to be.
Could he presume that his mother would want him to prohibit doctors from putting her on a machine that would breathe for her? From resuscitating her? What does resuscitation even mean? And how should he ask her these questions in her rare moments of lucid thinking?
I started by explaining intubation, in which a machine would breathe for his mother. That help seems a good thing, which it often is. But it does nothing to reverse a progressive neurological disease. My friend was also surprised to learn that his mom would have to be chemically paralyzed to avoid gagging when the tube would be placed down her throat. That would be temporary, but she would likely be heavily sedated while hooked up to the machine.
We moved to the Do Not Resuscitate order, or DNR, a somewhat misleading term. While there are many forms of resuscitation, such as fluids for the dehydrated or blood for the anemic, DNRs focus on whether medical teams should attempt cardiopulmonary resuscitation (CPR) if a patient's heart stops. This is a decision with tremendous consequences. CPR is most useful as a bridge between when someone's heart stops suddenly and when more advanced medical care arrives. For a person at the end of life, however, CPR rarely gains meaningful time. Rather than helpful, it can be deeply traumatic both for the patient who may suffer broken ribs and other injuries, and for loved ones who see the rough handling that CPR requires.
After explaining all this, I thought what my friend could really use was an important piece of context: in our health-care system there is momentum toward intervention. We are taught to act in order to save lives, I told him. We spend much less time stepping back to assess the patient's life as a whole. We may suggest to loved ones that further interventions may have limited utility. But unless explicitly told not to, we intubate and perform CPR. In our system, it is the patient or that person's representative who must tell the doctors to stop.
We want to do everything we can for our patients. We don't want to "give up." Yet additional interventions are often not in the patient's best interest, and knowing when to focus more on quality rather than duration of life is never straightforward. Ultimately, I told my friend it can be the most caring and courageous course for a patient and the family to refuse interventions.
At the end of our conversation, my friend looked down at his clutch of papers. He paused for a while and then looked up at me.
"There's no good way to do this," he said, "But there are bad ways."
From what I've seen, I had to admit, we are much better at advancing biomedical technologies than we are at dying in the way we aim to live: with dignity, preparation, and wisdom.