“I am so sorry …”
My apology diffused as I stood adjacent to the IV pole, triangulated between Ms. S, her husband, and her daughter. Ms. S, who was congenitally deaf and capable of lip-reading save for my N95, nevertheless immediately caught the sadness in my eyes. My pulse raced, and my heart sank as her face fell. She knew that her transplant – for which her family had paused their lives and submitted to a two-day hospital stay over New Year’s Eve – was, once again, not to be.
I had admitted Ms. S the day before, fulfilling my standard intern tasks of admission orders, medication reconciliation, and a history and physical exam. Ms. S, a 56-year-old woman with congenital deafness and end-stage renal disease secondary to type 1 diabetes mellitus, presents in anticipation of a possible synchronous pancreas-kidney transplant. I had also sat on the edge of her bed, propped against its plastic guardrail, and had walked through her surgery, its risks and benefits, and what she could expect post-operatively. Ms. S’s daughter, who had driven up the coast from her college campus to act as interpreter, patiently signed all my explanations into a dancing rhythm with her hands. Her spry mother nodded impatiently, as she had undergone this admission process twice before. The S. family then settled in, watching holiday movies together while our team adjusted our patient’s insulin regimen and completed her standard work-up of preoperative tests.
Every intern, I suspect, encounters moments of patient care that become poignant memories. These puncture our steady backdrop of progress notes, vitals, and labs. We learn through imitation and repetition as we carry out others’ orders, checking boxes off our trusty printout lists. Our administrative tasks scaffold each patient’s admission from door to follow-up. Yet every admission, I have learned, can be profound: full of nervousness, fear, or fingers crossed in hope of an organ that will bring a second shot at life. In these moments, the sanctity of the contract between the surgical team and the patient’s family is never clearer. Ms. S and her family looked up expectantly every time I crossed through her door, eager to hear some hint of progress. I learned to sign “Hello, my name is __” from a co-intern and laughed at myself as I pointed to the block letters on my ID badge, prompting a moment of color amidst long days of fluorescent lights and sepia computer screens.
I had popped downstairs to the cafeteria when my fellow called with the organ procurement team’s update. I was to discharge Ms. S and her family home, dialysis and insulin schedules intact. I froze by the elevator, deflated and unsure of how to proceed. As medical students, we role-play and memorize algorithms for breaking bad news; as interns, we wonder if we’re ever doing it right. As I later held Ms. S’s crestfallen gaze, familiar beads of perspiration prickled my back. I found myself caught between the perspective of our surgical team, confident in our decision not to transplant a suboptimal organ, and her raw disappointment. “I am so sorry,” I repeated, at a loss for words. “I would have loved to have taken care of you – but we need to wait for a better quality organ.” No matter how steadfast we are in our medical decisions, scientific objectivity always seems like an inadequate salve for a patient’s lost hope. In these brief moments, the walls we construct between our patients’ lives and our own crumble; we feel our personal losses imbued in theirs.
While part of the patient’s permanent medical record and vital to the continuity of care, discharge summaries are a dull, quotidian constancy for interns’ workdays. This is the last box that I check off my list, often long after a patient has left the inpatient floor. We use smart phrases and banal language to populate a long, faceless document. Occasionally, however, even our discharge summaries hint at stories underneath. That day, my summary felt inadequate, only hinting at what had happened in Ms. S’s room. Unfortunately, the donor organ was deemed unacceptable for transplant, and therefore the patient was discharged home in stable condition with her home medications resumed. Home to the same brave and uncertain routine of hope, mixed with disappointment and resolve that still touches this intern, and to further wait.
Permission was given to share this patient’s story.
Alexandra Highet is a surgery resident.
Image credit: Shutterstock.com
