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Posted by Ishani Ganguli June 10, 2013 08:30 AM
This week, I’m delighted to share a guest post from Dhruv Khullar, a joint degree student at the Yale School of Medicine and Harvard Kennedy School.
Lying in his hospital bed, he looked a lot like Santa Claus. A pleasant gentleman in his late 50s, he had a big beard and a big belly to match. He was a charming man - the kind that caregivers were drawn to and rejuvenated by. After a week of pre-rounding, we had developed a comfortable rapport and fell into a familiar routine. I would enter his room at 6 am to ask him about the night's events and perform a quick physical examination. Inevitably, he was already awake.
"Isn't it a little early for you to be up, young man?" he would ask.
"That’s why they pay me the big bucks," I'd respond, and we would share a smile. We both knew of the mounds of debt I was accumulating with each passing year of medical school. We also both knew that two of my last three meals had consisted of saltine crackers and diet Shasta that I "borrowed" from the nurses' station.
Despite his jovial demeanor, he was a very sick man. He had been uninsured for most of his adult life and had sometimes gone years without seeing a doctor. Intermittent and disorganized care had left him with two major medical problems: a weak heart and poorly controlled diabetes.
His heart was so weak it could barely pump blood to his extremities. No matter how warm it was in his room, his fingers and toes were always freezing. I would remove my white coat and loosen my tie before entering his room, and yet frequently found myself sweating as I reached out to hold his icy hand. He was on the heart transplant list.
His diabetes - which might have been better controlled if he had had regular check-ups and taken some basic medications - had damaged the nerves in and around his stomach. It no longer contracted with the strength and coordination needed to move food through his gastrointestinal tract. He ate small meals, but even these usually sat in the pit of his stomach until he was full, nauseated, and vomiting.
And yet, there was good news: it seemed likely he would receive a new heart. He was thrilled by the possibility of a healthy heart and a new life. But to ensure his body wouldn’t reject the transplant, he would have to take medications that suppressed his immune system. He would also have to demonstrate that he was healthy enough to get through the surgery and its aftermath.
Try as he might over the subsequent weeks, he couldn't keep those pills down. In fact, he couldn't keep much of anything down. Even water left him feeling bloated, and he required potent opiates to relieve the pain in his belly. He grew frustrated - with himself; with his nerves; and with his gut.
Watching him suffer, I started to wonder if the medical system had somehow failed him. It's a medical system - often hailed as the best in the world - that could replace a dying man's failing heart but hadn't been able to keep him healthy enough during his 30's, 40's, and 50's to enjoy the benefits of that technology. It's one that drew me in with robotic surgeries and proton-beam therapies, but often still struggles to provide preventative and well-coordinated care. It's a medical system that frequently overlooks the basic and effective for the novel and cutting-edge - leaving many patients who desperately need the former instead desperately seeking the latter. We see this in the aphasic woman whose uncontrolled blood pressure resulted in a stroke; in the uninsured man whose cancer went unscreened and undetected; and in the diabetic patient whose stomach no longer contracts.
Late one evening, I sat in on a somber discussion between my attending physician and my once-jolly patient. The attending spoke softly but authoritatively. She told him that he was no longer a candidate for a heart transplant, but that we would do everything possible to keep him comfortable during his remaining months.
He grimaced - the blow to his psyche now dwarfing the pain in his belly. I swallowed hard as I saw tears well in his eyes. He glanced at me. We both knew he wouldn't make it to Christmas this year.
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