Morning Rounds, With My Friend

By RAMY SEDHOM, MD

Rutgers-Robert Wood Johnson Internal Medicine

It was a month into my internship and she was the patient I’ll never forget. Like many of my co-interns, I wondered about entering internal medicine. My patients never improved, bouncing in an out of the hospital. I became uncomfortably familiar with chronic and terminal medication conditions. I had a quick acronym expansion for my death notes. I was chronically tired and grew cynical.

It was the last hour of my floor shift and I had a new admission. Young mother status post stem cell transplant presenting with shortness of breath. She had already fought a long battle with lymphoma. Fever, anemia, thrombocytopenia, stroke, and graft versus host disease, were terms she understood too well. As the intern on service, I saw Rachel early each morning. Her husband was always bedside and a picture of her daughter covered her cellphone. She maintained her sense of humor and did not interrupt my digging and poking each morning. She politely answered my innumerable questions about bowel movements, sputum, and her urination.

Days went by and we grew more familiar with each other. It was my overnight shift and I had stopped in to say hello. Despite a week of being her doctor, it was the first time we discussed anything nonmedical. I learned of her favorite foods, her former job as an English professor, and what she dreamed her daughter would grow up to be. I grew fond of Rachel and began to look forward to seeing her each day.

Unfortunately, she clinically worsened. Her blood pressure dropped along with her oxygen saturation. She began having abdominal pain with diarrhea, she stopped urinating, and her labs were mostly abnormal. Eventually, she was transferred to the intensive care unit for increased work of breathing – conveniently, my next rotation.

I encountered her this time on noninvasive mechanical ventilation. It was the first time I had seen her afraid. I took off her mask to complete my morning interview. She began to cry. We discussed her code status and she pleaded with me to not let her die in pain. Though she wanted to be there for her daughter and husband, she did not want to be intubated. Later that day, she became diaphoretic, dyspneic, and began coughing blood clots. Her chest imaging and bronchoscopy confirmed pulmonary hemorrhage. With her neutropenia, and relapsed malignancy seen on her chest CT, Rachel had expressed a desire to approach comfort measures. She appeared remarkably calm.

I sat with her husband hours later when she became too obtunded to engage in conversation. Her six year old daughter visited the hospital for the first time in her month long hospitalization. She held a pet rabbit named Katie. I squeezed Rachel’s hand after my routine examination. Two hours later, I was called for worsening respiratory distress and oxygen desaturation. I knew her time had come. I pronounced her before my end of shift, and came back to express my condolences to her husband, who sat expressionless the entire day. He gave me a hug and told me that Rachel considered me her new friend since being hospitalized one month prior.

As I walked back to the call room I began reflecting on his words.

“Friend.”

I was grateful for the respect and trust she offered me, the dazed intern. I realized that caring for her and smiling each morning was the only part of my day that required little effort. It was also the only part of my care not mentioned on teaching rounds – ‘friendship.’ I cherished the words and thought about them for the rest of my intern year.

I will always remember Rachel. She changed the way I see patients. Though I will always read and try to improve my skills as a clinician, I’ve already learned the most important aspect of being a physician – caring for the patient. I learn each day that patients expect many things from their doctor – support, kindness, empathy, and sincerity – often far more therapeutic than guidelines driven treatments. There has been nothing more rewarding than meeting patients, who despite declining from chronic medical conditions, enjoy seeing me, their doctor. I hope to always treat patients with the same reverence I gave Rachel. It is possible, no matter what the outcome, to make a difference in someone’s life.