Thursday, March 09, 2006

The Journey Continues

I arrive at the hospital to visit my patient. The ID Team (Infectious Disease) is gathered around his bed, poking and prodding, examining. It's right out of a movie or TV show: the big honcho ID doc surrounded by three residents who all give their input about the case. My arrival, which is not always altogether welcome in such a high-powered medical scenario, is greeted with surprising deference, and my input and ideas are readily accepted. I have a good working relationship with three of the four, which greases the interdisciplinary wheels. We discuss the case, and I do my best to connect personally with my patient, trying to assuage the clinical feeling of this little tete-a-tete. Luckily, one of the residents speaks Spanish and had put him somewhat at ease before I arrived on the scene.

This is one of the challenges in a teaching hospital---residents and medical students need to "round" with the docs and test their mettle, honing their skills of assessment and diagnosis. The problem for the patient is that there are many, many cooks in the kitchen, a plethora of examinations and assessments, and a literal parade of strangers traipsing in at all hours of the day and night to do their thing, interrupting naps and my patient's only diversion, the Spanish-language soap operas, or "novelas". If the patient does not speak English, all of these strangers seem even more foreign when communication is so minimal.

When a patient is as complicated as mine: HIV, diabetes, a non-healing wound, actively invasive and non-operable cancer, as well as previous TB with underlying pulmonary disease, the number of specialists and doctors involved is dizzying, and it's part of my job to keep the patient's psychosocial needs front and center, as well as feed the team the information which I have gathered over the last several years of intimately connected nursing care.

As they take their leave of the bedside, I notice that---typical doctors---they leave a trail of used exam gloves, gauze, forceps, and other detritus for the nurse to clean up. Nurses began as ersatz handmaidens for doctors, and that attitude persists to this day. It wouldn't take much effort for them to clean up a little as they leave, but the experienced doc is not only teaching these new docs the art of medicine, he's also teaching the art of being a doctor, which unfortunately includes ignoring the needs of nurses, using nurses like maids, and sweeping on to the next patient with a sense of self-importance and circumstance. I recommend seeing the movie (or original play) "Wit", starring Emma Thompson. It is an amazing illustration of the inhumanity (and humanity) of illness, doctoring, the experience of the ill during institutionalization, and the conundrums of modern medicine.

For now, the challenge is supporting my patient as he begins to face the ever-expanding and changing landscape of his illness. He is beginning to grasp that the cancer will not go away, the (larger than) fist-sized wound in his bottom will never heal, and his level of debilitation and dependence will only grow. I wonder if his third-grade education really allows him the intellectual fortitude to fully grasp the extent of his illness and its ramifications.

Can his friends and one local sibling rally around him and provide the care he will need at home with the support of hospice? Would his aging father come from Puerto Rico and care for him? Can I direct and manage this team of people to keep him comfortable, put out fires, and deal with the continuing challenge of symptoms, pain, and suffering that is inevitable when and if he does indeed go home? Will we need to decide that going home is out of the question and a nursing home is the only option?

These questions swirl in my mind tonight as I ready myself for recovery and sleep. This particular soul's journey is intertwined with mine, and I'll be seeing it through to the end. I only hope the end---and the process of arriving there---does not become unbearable for him and for those who witness his journey.
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