Philadelphia, Pennsylvania, United States (Spring 2016)
Seattle still slumbers under a blanket of mist at four in the morning, a suspension of droplets that seems to swallow sound, so I struggle to hear even my own footfalls during my morning run to work on the inpatient service. Though the run clears my mind and dusts away the final gossamer threads of sleep in preparation for the day, it has come to highlight the loneliness of this away rotation in a city so far from my home.
I arrive long before the residents to review my patient’s labs and overnight progress, to begin my notes in the quiet hum of overhead fluorescence in the empty call room. This morning a new patient is on my census. Peter is young, around my own age and was admitted overnight. His admission note is brief, including a history of diabetes (“Likely uncontrolled type one”), diffuse abdominal pain for roughly a week (“But, patient is a difficult historian”), and labs to support his presumptive diagnosis (“DKA with concomitant pancreatitis”). During sign-out I am told, “Good luck,” by the weary night float resident. “This one’s difficult.”
I take my time getting to Peter, not because I am reluctant to see him, but because I linger with my other patients. I would like to say this is an effort to practice thorough, patient-centered medicine, but in reality, the patients I follow are the closest thing I have to friends here and their bedside is where I feel most close to home.
By the time I reach Peter’s room, dawn-light sifts through windows to paint the space in shades of gray. His roommate, a grandmotherly looking woman, smiles and waves as I enter their room with a knock.
Peter is huddled with his knees drawn to his chest, each breath near a groan, his body hill-like under the folds of thin sheets. I settle next to him on the bed and lay one spread hand carefully on his shoulder, “Good morning Peter, I’m sorry to meet you like this, but my name’s Ethan. I’ll be the medical student following you while you’re here.” He grunts in response and grimaces at the effort. “Your pain is bad isn’t it?” It’s a leading question, one of the first things we are cautioned against when learning patient interviewing, but it doesn’t take a fourth year medical student to know this patient is hurting. Peter bobs his head minutely in response. “Still in your stomach?” Again, he gives the slightest of nods. I glance at his bedside monitor to confirm his vitals are stable. “Listen, I don’t want to keep you up, I know you’re in pain; that rest will help. We can talk more later about what brought you here, but for now I want you to know we’re doing what we can to fix you up. Can I answer any questions before I do a quick physical and get out of your hair to let you sleep?” This time he shakes his head slowly side to side. I move as quickly and gently during the physical as I can, but it is obviously uncomfortable. By the time I reach the abdominal exam, even the weight of my stethoscope resting against his stomach causes a gasp of pain. Slipping silently from Peter’s room, I wonder where he’s from, where his family and friends are, how his insulin regimen fell through to cause this DKA.
Over the ensuing week I follow Peter, his course is fraught with setbacks. First a DKA that resolves exceedingly slowly despite our insulin drip and vigorous Intravenous fluids. Then Peter’s pain remains resistant and he’s unable to hold food or water. We eventually find his pancreatitis has been complicated by necrosis and he moves to the ICU.
Our conversations remain brief due to his discomfort, but I am able to slowly stitch together the basics of his life. He is homeless, his parents and friends either geographically or emotionally distant. Life on the streets makes regular insulin dosing difficult to track and he is not followed by a primary physician. When we step his care up to the ICU, I explain to him the gravity of his sickness and ask if there is anyone I can call on his behalf. He slowly nods, “Mrs. Taylor,” his words sound thin and insubstantial between his cracked lips, “my 6th grade teacher, she likes to know how I’m doing.”
Mrs. Taylor answers on the second ring. I introduce myself and tell her about Peter’s condition. She is distraught to hear how sick he has become and even more so that she’s on vacation with her family and unable to visit. “He’s always been such a good kid,” Mrs. Taylor says, voice thick with either sadness or nostalgia, or maybe both. “Even as my student, I suspected he didn’t have much to call home, so I did what I could to find him shelter, food…” She drifts off for a second and I can almost hear the pain in the silence, “Thank you so much for calling Ethan. Please convey my wishes for health to Peter. Tell him I haven’t forgotten him.”
It is after this conversation that I fully realize how lucky we are Peter made it to the hospital at all. Even worse, lurking behind this last thought is the terrible after-image of Peter curled alone on the street, much as I found him the first day in the hospital. This time though, he is under the cover of dirty newsprint instead of hospital-grade sheets. In this near-reality, his breaths don’t come in throaty groans. Here there is only the silence of lungs no longer turning air.
I still run to the hospital each morning and my mind churns through the details of Peter’s case. My own loneliness seems so small now, so trivial next to Peter’s and I wonder if he feels his solitude anymore or if it has become as muted as the misty city before the dawn.
By the end of my rotation, Peter has finally turned a corner; his recovery and discharge are only days away. I realize he may leave the hospital never to be seen again by the staff with whom I shared his care. But to me, he will never be a stranger. Each morning I run through damp gray, I know Peter lingers unseen beside me. Each night I curl alone, knees to my chest against the cold, I know that somewhere Peter does the same and my loneliness seems a bit smaller, a bit less empty.
ETHAN SELLERS, MSIV is a senior medical student at Jefferson University in Philadelphia. He grew up in rural Lancaster County, Pennsylvania with his brother Jordan, parents Bill and Lauri, and faithful canine companion Spotopotamus. When not preparing for a career in Family Medicine he can be found writing poetry, playing board games, and hiking through the Californian countryside with his partner Van.