“And then he said, ‘I … I just want to help people you know?’” The table burst out laughing. I struggled not to spit out my breakfast burrito while chuckling. The laughter slowly died down, and I took another gulp of stale hospital coffee. My classmate was recounting the story of one of the pre-med undergraduates he had begun to mentor. I was too tired to think clearly about why I had laughed — I only knew that his story had tickled some deep feeling of irony about what we were doing there, that there was some simultaneously comedic and Kafkaesque tragedy about it all. It was our 28th hour on call on the acute care surgery service. We were a haggard, exhausted bunch, no doubt a bit drunk from sleep deprivation after spending a night in the trenches. I took a last bite of burrito — too much, as always — and washed it down with more coffee before taking the elevator back to the fifth floor.
I was greeted by a nurse with a loud “Good morning, doc!” as I walked onto the unit.
“Jaycen. I told you, man. I’m not a doctor yet, you don’t have to call me doc.”
“Eh, you guys are all pretty much docs to me. Have a good day, doc.”
I found an unoccupied computer and opened the note I had started earlier:
Chief Complaint: 51-year-old Hispanic male with uncontrolled Type 2 Diabetes Mellitus presents with non-healing gangrenous left lower extremity wound over his medial metatarsals.
Mr Suarez had come in with a blood glucose level of over 500 — too high for our tests to read, a fever of 40 degrees Celsius and a rotting wound over his left toes. When he came in around 11 p.m., I asked him if he had known he had diabetes if he had ever heard the word as I dug around with my probe in the festering, green wound — his diabetes had long ago caused his nerves to die and he felt no pain. Click. I had touched bone.
“Yeah doc, I heard it before but I thought I could just take vitamins and stuff you know?”
“Did somebody talk to you about what diabetes means? Do you have a primary care doctor?”
“I think so. I don’t really remember though. I don’t think I qualify for health care so I didn’t try to find a doctor. Anyway, are you going to give me some medicines?”
“Let me go get my resident. He’ll talk to you about the plan.”
I already knew the answer to his question. We amputated most of his foot a couple of hours later.,/p>
I finished up my note, and I thought about my friend’s story about his pre-med mentee. When I was in his shoes, I had no doubt given some version of that same answer many times when asked why I wanted to be a doctor. I suppose it wasn’t wrong answer — we did help Mr. Suarez, like a firefighter helps the smoldering wreckage of a building. We put out your fire Mr. Suarez, sorry about your house, though. Plenty of helping being done here.
As I closed my note, I realized I was angry — not angry at the system and how it had dropped the ball and let a patient slip through the cracks. I was angry at him. At my own patient. He had just lost his left foot, but I was livid thinking about how he’d never bothered to even try and find out what diabetes meant for him. I was angry that he had waited for months as his foot rotted away before seeking help. I had sensed the same feelings in my resident earlier, and I had understood in that moment, the indifferent way in which he’d delivered the news that we’d have to amputate. I knew that I wanted to lay blame with the patient for this, because he was a more tangible target that some specter of a failed health care system. My train of thought halted as my head hit the pillow on my bed at 12:30 p.m., 30.5 hours after I had started my shift.
6 months later
The attending physician had a warm, genuine smile, like a hug without using his arms. I watched him use it now to put his newest patient at ease. “So, Miss Jimenez, I’m sorry you ended up having to get a surgery for your appendix, but it’s a good thing they discovered your diabetes this early. I’m going to write you a script for some Metformin, and I want you to take it every day twice a day. It will control the blood sugar.” Before Miss Jimenez could open her mouth to ask a question, the attending walked out of the room to get a prescription pad and put out one of the many fires that had no doubt crept up while he was seeing this patient.
I sat there awkwardly, observing the mild confusion in her face.
“Any questions miss Jimenez?”
“So … I take this drug and the diabetes goes … away?”
I craned my neck and peered out into the hallway to see my attending on the phone speaking animatedly with somebody, gesturing wildly with one hand while writing the prescription for her Metformin with the other.
“Not quite,” I answered.
Miss Jimenez was young and generally healthy, still in her early 30s but overweight and diabetic. Before I could answer any further, my attending hustled back into the room with the prescription. “Okay, here you go, make sure you check out at the front desk, and we’ll make an appointment for you to follow up. Nice to meet you again!” He gripped her hand firmly, gave her a famous smile, and walked out to attend to the next three patients in line to see him, all of whom had waited at least half an hour past their appointment time. Par for the course in the busy medical practice I had been working in.
I looked at Miss Jimenez, who had begun to pack up her things, the prescription still in her hand. I wanted just to say goodbye and let her go on her way. She had her medications; she knew when and how to take them. Surely she was smart enough to figure it out for herself: to look up her disease online, to seek help if she didn’t understand something, to go to the doctor if she started to have nocturia or blurry vision, to take her medications on time, to refill them when she ran out, to not let a foot wound fester for months before seeking help.
Surely, things would be fine, and somebody else would eventually clear up any misunderstandings she had about her disease. Besides, I was just the medical student — who was I to turn her life upside down by using that terrible disyllabic “chronic” qualifier in front of her disease.
As I watched her slip the script into her purse, I knew that my rationalizing was a way for me to avoid a more disturbing truth — that in front of me was a patient slipping through the cracks right this very second. And that I, in all my insecurity and ineptitude as a 3rd-year medical student, the least qualified person wearing a white coat and a stethoscope in this building — I was the only one witnessing it.
I looked down at my shoes for a moment and gathered my thoughts and my words and my courage. She put on her coat. Before she could leave, I stopped her.
I turned her life upside down as kindly and patiently as one can do so. I told her that she might have to take medications for decades, if not longer. That it might be for life. That she’d have to be vigilant about exercise and her diet. I talked about some of the consequences of uncontrolled diabetes. I told her that it might get better, but it might also never go away.
She thanked me at the end and made an appointment with the front desk — I could see she was still trying to process everything I had told her. It might have been for nothing. Maybe she would have taken good care of herself anyway. Or maybe she’d forget everything I said and go on with her life like normal until she ended up in the emergency room one day 10 years from now with osteomyelitis and lose her leg at the age of 43.
But I guess I was glad I had tried. We shook hands in the hallway one last time before she left to return to that world of missed appointments, and loss to follow-up, and poor diets, and forgotten refills — the real world outside, the world I wanted so desperately to shield her from. As she walked out the door, I told her “Take care, good luck” — four words wholly inadequate to convey the raging tempest of anxiety and hope and fear that I felt for her.
Benjamin Nguyen is a medical student who blogs @Ben.Nguyen on Medium.
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