Friday, March 24, 2006


In some relatively recent posts, I discussed a patient for whom I had gone above and beyond, arriving at a point of seemingly no return. Having lost faith, I had disengaged somewhat and waited for the toubled gentleman to come find me. His "MIA" status precluded my doing much for him anyway, since even his siblings could not locate him on any given day. His was a sad case of self-neglect and complete disenfranchisement from the system. His role as a human time-bomb was assured in my mind.

That said, he surfaced a few weeks ago, living in a boarding house with his brother, looking cleaner and more well-kempt than he had for some time. I managed to visit a few times, sort out his meds, and begin to make some plans. With his consent, I contacted a facility that I felt would be perfect for him: locked ward, active and compassionate detox protocols, as well as subacute care for his many complex medical needs. After a 25-page fax to said facility, he was refused based on the fact that he could not be admitted as an outpatient. He would just have to get sick and go to the hospital, and only then would they consider him a candidate. Other facilities basically said the same thing, and his sister--agitating for an inpatient stay for her wayward elder brother--was enormously disappointed.

Several days later, my patient arrived unannounced at the clinic with reports of vomiting and abdominal pain. We did a quick assessment and asked him to return in one hour for an urgent appointment. He and his brother (who accompanied him)left and returned at the appointed time. Unbeknownst to me until later, they left after only a thirty minute wait (a very short time at our inner city clinic) and disappeared into the anonymity of the city. I assumed he would call or end up in the ER if things got worse. It was out of my hands now.

Lo and behold, late last week I heard that said patient had been admitted into the ER under the auspices of the Thoracic Surgery service. Unable to glean from the on-line chart the reason for his admission, I went home and decided to follow up the next day. Sadly, the news was devastatingly tragic: it seems that his severe vomiting---perhaps initiated by combinations of alcohol, cocaine, and other substances---has been so severe as to rupture his weakened and damaged esophagus. The entire lower half of his esophagus had burst, gastric contents spilling into his chest cavity and upper abdominal cavity. Eight hours of surgery later, he landed in the ICU---where he is to this day---surprisingly breathing on his own, having torn out his breathing tube in the thrashings of withdrawal. With no functional esophagus, a gastric tube fof feeding, days of unconsciousness, paradoxical breathing patterns and global blood dyscrasias, he is most likely not long for this world.

His sister called me the other day to ask about our discharge plans. She said that she understood he would not be going home any time soon, and she wanted the best care for him. I gently explained that there was a good possibility he would never be back, that he could remain in this state for some time, and that his prognosis for recovery was very slim. (Actually, for an esophageal rupture of this type, mortality is approximately 95%.) We lamented how the facility I had contacted had refused him, that he could not be admitted without first being acutely ill, that he had consistently refused to care for himself, and that she and her other siblings had lost someone who should have been a role model, a family anchor, the eldest of a large group of parentless siblings. It was a poignant moment as we shared over the phone line the very real and singular reality of the untimely demise of a lost soul, her eldest brother.

I do not see this as a failure, per se. It is simply a fact that there are sometimes individuals who cannot be saved from themselves, and no matter what I do, there are circumstances beyond my control as a clinician and human being.

Standing beside that ICU bed, I made my peace with this unfortunate and critically ill man, blessed him on his journey, and prayed that he is not in pain. The rest is up to him and the forces at work as his body struggles for life, and as his soul does the work it must when its corporeal home is damaged beyond repair. As his desperately ill body clung to life in that sterile room, was his soul somewhere above or around me, slightly disengaged from that shell, witnessing from its vantage point the desperate nature of the human struggle unfolding on that bed? I spoke to him in Spanish, wished him well, and took my leave of that body bristling with tubes and the technology of desperate measures. The term "Godspeed" came to mind as I turned away, and the meaning of that term, in that moment, was clear as crystal to me. Godspeed, and blessed may you be on that journey we all must take alone. May you finally be free of all suffering.
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