In my third year of medical school, I started a rotation at the nearby VA hospital. Walking toward the polished glass doors that morning, I saw my reflection — clean white coat, assured expression to cover up how lost I felt. It was my second clinical rotation ever, and my first time at the VA.

I found my team and soon met a patient I’d be seeing for the next month. His name was Jim. He’d already been hospitalized for a week — and he wasn’t leaving any time soon.

At 70, Jim had no muscle or fat on his body. His gray skin hung like a sheet over the ridges of his skeleton, and his bony arms were covered with tiny puncture holes from years of injectable drugs.

Despite Jim’s weakness, he clearly didn’t want to be hospitalized. Each morning, he’d frown at me through bloodshot eyes and snarl, “When the hell are you gonna let me leave?”

Trying to fix Jim was like trying to fix a leaky pipe — we’d plug one hole and find three more. First, we treated him for drug-induced delirium. Then he spiked a fever from an infection. Its source was a football-sized abscess of pus below one kidney. We gave him antibiotics and ran a drain from the abscess to a plastic bag by his bed.

What surprised me most was what a difficult patient Jim was. He scowled and swore at everyone. I had treated patients who were angry and upset, but Jim went beyond that: He seemed to despise us.

“How’re you feeling?” I asked one morning.

“Get away from me,” he grumbled. “You’re just keeping me here for the money.” He shifted in bed, glancing at the pus-filled bags. “You haven’t done shit, and I’m not gonna sit and watch you get paid for it.”

A nurse who had brought in his medications eyed me sympathetically.

“He’s a student,” she said. “He’s paying to be here.”

“Well, you can shut up!” Jim snapped. He turned to me. “And you can get the hell out!”

“All right,” I said. “Anything el…”

“I said get the hell out!” His voice cracked with frustration.

I wanted to talk more, but I knew that pushing him would only make things worse. I left, reflecting that I’d never seen him smile.

Why does Jim hate me, and seemingly everyone else? I thought. He doesn’t even know us.

Jim was unlike anyone I’d ever met. It seemed that no amount of care or kindness could unravel the pain and anger knotted inside him. This confused me: I’d always thought that kindness could heal others. I wanted to help him feel better, but nothing worked.

Curious, I looked into his medical records. He’d fought in Vietnam, then lived on the streets for decades, abusing every drug imaginable. He had no family and only one elusive friend. He had next to nothing. But still, somehow, he’d survived.

I wondered if his attitude had helped him do that. Maybe years of survival had taught him to hide behind anger and aggression; maybe he’d never had the chance to trust anyone. Either way, it didn’t seem realistic that I, a 24-year-old student, should expect to change his attitude. Slowly, I started to realize that Jim wasn’t an equation for me to solve. He was more like a story: unruly, unpredictable, uncontrollable.

As little as I knew about Jim’s story, knowing that he had one helped me to remember that he wasn’t simply the mean old man on the fourth floor. He was, instead, a person shaped by many bad things that had happened: war, drugs, sickness, homelessness.

Unfortunately, the defiance that had kept Jim alive outside the hospital was now his biggest enemy. He refused food and medication, and his abscess enlarged enough to need surgical drainage.

Surprisingly, when the surgeons met him to explain the procedure and ask for consent, he agreed. I smiled, thinking, We’re finally moving in the right direction.

But when they came to operate, Jim yelled and cursed and tried to yank out his IV, threatening to leave. The surgeon’s note read: “PROCEDURE CANCELLED. PATIENT REFUSED CONSENT.”

My team let out a collective sigh. “So close,” the chief resident muttered.

For days after, Jim sat in bed wasting away, his bones as sharply etched as a figure in Gray’s Anatomy. His mental abilities also waned.

Our biggest problem became whether he had the mental clarity to make his own medical decisions. Sometimes, he was feisty and alert; other times, too confused to remember his own name. And he refused every treatment we suggested. He had no living will, and nobody willing to make his decisions.

One physician believed that hospice was called for; others wanted to continue treatment. I felt as uncertain as anyone. Then I remembered something.

Shortly after Jim had rebuffed the surgeons, he called me over.

“How can I help you?” I asked.

“I don’t wanna die,” he muttered, then closed his eyes.

“Jim, are you awake?” I asked. No response. I checked his vitals: normal. “Are you OK?”

“Just get outta here.” He waved me off with his skeletal arm. “I need sleep.”

I walked away, surprised. I hadn’t realized that someone like him could fear death.

This reminded me that, in some important way, we were alike. It didn’t matter how tough he acted or how sick he was. He felt the same as anyone else would — the same as I’d feel. He wanted to live; he needed hope.

On my last morning on the unit, Jim slept peacefully, his chest moving gently. He yawned, and his face wrinkled into what looked like anger. I’d seen him make that face many times before, but this wasn’t the same. He was asleep. For the moment, it seemed to me, he felt no pain, no hatred, no anger.

I wondered how often I’d misread Jim’s expression, assuming that I knew how he felt or what he wanted. Jim was someone who’d survived bullets and drugs, streets and jungles, jails and hospitals — experiences unimaginable to me. It had taken me a month to see that he was, and would remain, a mystery.

After my rotation ended, I kept wondering about Jim: Would he leave the hospital, or spend his last days there?

Two months later, on another VA rotation, I got an answer. I searched Jim’s name on a hospital computer and clicked open his chart. Large text popped up on the screen: “DIED NOV. 10, 2018.”

I stared at the screen. The bright light blurred as I lost focus. Part of me had expected this. Another part had held out hope, just as Jim had.

I remembered Jim’s frowning face, and all the time I’d spent analyzing his expressions. I’d assumed that caring for Jim meant that I needed to understand him completely. After all, I’d worried, shouldn’t I know my patients?

But now I thought, Didn’t I know enough?

I didn’t need to know everything about Jim. I didn’t need to know what made him joyful or hopeful — if anything did. I only needed to remember what he’d already taught me: that a snarky, rebellious old survivor, alone and unknowable, can still be seen and valued.

Zach Reichert is a medical student. This piece was originally published in Pulse — voices from the heart of medicine. 

Image credit: Shutterstock.com