Viejo

I did not know that the first time I met Viejo was the last time I would see him as himself. At the time I was a medical student on a rotation that gave me junior physician-level responsibilities, and with it the chance to prepare for my upcoming transition, one I had worked for years to attain: becoming a doctor. A trusted healer. A source of comfort and competence. A cooperative team player. I was painfully aware of my own shortcomings—not enough knowledge or experience—but deeply devoted to the acquisition of both, and to the creation of meaningful connections with my patients.

Viejo, as his wife lovingly called him, was my first patient. His bright eyes glowed behind wide, plastic-rimmed eyeglasses, his handshake firm, his smile trusting. But Viejo’s story was an all too common tale among the low-income population my public hospital serves. Unable to afford regular preventive healthcare services, he had presented with mysterious new “back pain” that, through a CT scan, revealed itself to be late stage cancer, already metastatic to the bone. Viejo and his family—his dear, devoted family—came to us hoping for a timeframe for recovery, and instead received an estimated expiration date. The entire scenario felt cosmically unjust, particularly for Viejo, a sweet soul, barely past middle-age, adored by his wife (“of forty years!” she always reminded me), idolized by his children and grandchildren, and beloved by his many neighbors and friends who milled about his room nervously during that first week post-diagnosis.

His wife was the most devoted of all. She brought plates of savory rice and platanos every day to sustain him, but as the days passed, his appetite diminished, and the aluminum dishes would pile up at the bedside. She slept over nightly, balancing her short, stocky frame across two flimsy folding chairs, enduring the cacophony of beeps and hums from vital sign monitors. She insisted on changing his adult diapers, as he began to lose control over his bowels, and administered his enemas when his pain medications slowed down his digestion. She held his hand through every blood draw, and attempted conversations with him even as he had less and less strength to talk back.

In a single week, our patient deteriorated before our eyes, but his wife still saw the old Viejo, still talked to the old Viejo, still interacted with the old Viejo. At night I would return home to my own husband and as we dined together, I couldn’t help but think of Viejo’s wife feeding him spoonfuls of rice, persisting even though he rarely took a bite. Did she think of their forty years worth of dinners together, every time she put a spoon to his lips?

On our initial prognostic assessment, our team of internists and oncologists estimated Viejo might have six months left, maybe even a year, depending on the makeup of the tumor we had biopsied. But our stoic, peaceful patient decompensated faster than we anticipated, becoming a torture victim of the cancerous lesions riddling his skeleton.

“Can we please keep a close eye on his pain?” I asked his nurse, Maryann, on whom I began to rely on for this crucial data. We increased his opiates to keep pace, but day-by-day his body systems slowly began unraveling. Maryann called me dutifully to provide updates on his low blood pressures, rapid heart rates, and oscillating oxygen levels. His unexpected deterioration forced our team to reevaluate his prognosis, now more likely a matter of weeks than months.

Our team gathered Viejo’s wife and daughter into a small conference room to share this impossible news, seated in a circle of folding chairs, all facing one another, all avoiding one another’s faces. Two weeks, we explained, gently. His daughter’s expression twisted into a silent look of horror. His wife wailed into the ceiling tiles, “Dios mio, no, no, no.” My own heart felt hollowed out as we explained there was nothing more we could offer to extend his days, that we could not give them what they wanted, what we all want—more time.

Though I kept a calm face, afraid that my true feelings would only provoke further sadness, my chest tightened at the grief pouring out of this loyal wife and daughter. Viejo’s daughter was nearly my age, and we had developed a friendly rapport. His wife had become integral to my daily examinations, greeting me every morning—“Hola, doctora!”—dutifully reporting overnight events, but also telling me a new story, everyday, that spoke to Viejo not as a sick patient but as the man he was prior to this moment. I learned he had adopted poor children from his neighborhood and ensured they received an education, that he loved bachata music, and dancing with his wife, and that he had worked his way from penniless immigrant to father of a college graduate. It was difficult for me to visualize that accomplished, proud man in the tiny, suffering body that lay in his hospital bed. But his wife did, everyday, so clearly.

Over the next week, Viejo’s pain levels skyrocketed beyond what his intravenous morphine could cover. Still new to the computer systems and pharmaceutical protocols of the hospital, I fumbled around to renew a higher-dose fentanyl patch that our team decided he would now need. After a few failed attempts, and frustrated with myself for creating a delay that might prolong his suffering, I sought out Maryann to ensure she saw the order I placed, but couldn’t find her in the hallways. I kept working on other tasks, and an hour later called her to check in. Had she given the pain medication?

“I couldn’t give it to him yet, because of the way your order was written,” she said over the phone, matter-of-factly.

Couldn’t give it?! Every iota of my frustration—from all aspects of this family’s tragedy—accumulated into a furious flurry. My heart raced at the thought of him suffering due to a bureaucratic administrative obstacle. The words of protest spilled out of my mouth before I could think them through:

“But can’t you see he’s suffering?!”

I knew I was speaking defensively, partly from a desire protect my patient. But I was also indicting myself with this question. I felt guilty for having written the order incorrectly, and I felt helpless in the face of what seemed like insurmountable suffering. I knew my outburst was not only inefficient (a simple, “Could you explain how to write the order correctly, then?” would have sufficed), but also unfair. It was wrong of me to cast blame on Maryann, as if she had created the error herself, as if it were her fault the hospital medical record system was antiquated, as though she didn’t care about his suffering.

Maryann immediately reprimanded me for my passive accusation. Paralyzed by my anger—at myself, not at Maryann—I was unable to reply. In an instant I had lost sight of all the things I had set out to be: I had failed to bring my patient comfort, I had failed to be a good teammate. Tears welled in my eyes, and I rushed to the bathroom to wash my face before getting on with re-ordering his medications, and the rest of the day.

Hours later, I had wandered into the small supply closet to gather tools for a blood draw, when Maryann came through the doors. Our eyes met, and I cast my glance downward, ready to be ignored, to be shunned, to be seen as “that” type of future doctor, the kind I never wanted to become. But instead, Maryann bravely made a connection.

“Are you OK?” she asked.

I raised my eyes back toward hers, moved by her compassion. For all she knew, I really was a careless, mean-spirited, self-centered student. Instead, she assumed the best of me. She treated me as if my behavior was aberrant from a nobler baseline. She gave me an opportunity to show myself.

“I’m so sorry, Maryann,” I said. “That wasn’t me. I lost myself for a moment.”

She approached me, my hands still clasping tubes and tourniquets, and embraced me, firmly. “This might be your first, but it sure as hell won’t be your last,” she whispered into my ear. Pulling away, she resumed her tough stance as a seasoned nurse. “I’ve been doing this for twenty years, and it doesn’t get easier. It’s good that you care about your patients. But you have to trust that we all do, too.”

I felt transformed by Maryann’s grace. Rather than respond to my anger with reciprocal ammunition, she saw my frustration and my sadness—as she must see surge through so many students, doctors, and nurses, as she must feel pulsing through her own vessels as well—and gave me an outlet to release them. She accepted that I wasn’t being myself. She was willing to look past that, beneath that, and see me there: a caregiver who cared about my patient, who despised his suffering, who felt like a helpless healer. After our conversation I thanked her, and moved along to my next patient, to the rest of my shift, with her kindness surrounding me like a protective aura.

By four weeks out, Viejo’s steadily worsening pain required a level of drugs that obliterated his consciousness; he was unrecognizable to me from the person I had met weeks prior. Yet his family dutifully continued to attend to him everyday, connecting with him no matter how aloof he seemed to me. No matter how strong his medications, he still smiled when his wife’s hand clasped in his. No matter how thin his face became, his tortured grimace still loosened when he heard familiar voices at his bedside. As I completed my four-week rotation, his family prepared to move him to hospice, and I encouraged his daughter to reach out if I could ever be helpful in the future.

Two weeks later, I awoke to a brief text message from his daughter: Hi Doc. Dad passed away at 3AM. As I dressed and bid farewell to my husband that morning, I thought about Viejo’s family and their goodbyes, the goodbyes we all experience over time, and how precious they become only when we realize they may be limited. How many times in their forty years had Viejo and his wife bid one another goodbye at the start of a work day? How many times did they lie beside one another and offer goodnights and sweet dreams? Did it ever cross their minds, as it crossed mine now, that there would one day be a last time?

Viejo’s daughter asked if I would come to his wake, and I was happy to oblige her request. It was March but the breeze was still brisk, a winter chill clinging to the city air. I found my way to the small funeral parlor in the Lower East Side, a brick building packed to the brim with guests, their bodies overflowing onto the street as if it were a sold-out concert. It appeared that the entire neighborhood had gathered to pay their respects to Viejo: somber adults and hyperactive grand-children, folks in leather jackets and decorative gowns, a mosaic of skin tones, arriving on foot, by cab, and in wheelchairs, the elders leaning on canes as they slowly approached the sadness of having outlived a boy they once raised.

As I inched through the throng of guests, my gaze gravitated toward a few posters filled with photographs from Viejo’s life. In the pictures, he looked even more vibrant and alive than that first day I met him: his round face, his wide glasses, his beaming smile. In each photo I spotted Viejo as a father, a husband, an uncle, a brother, a neighbor. I saw Viejo in relation to those who loved him; an identity shaped not only by his self-perceptions, but by the way others experienced his energy and presence.

These photographs seemed to represent him so well, crowding out of my mind the images of his face contorted with pain, and the pasty, molded smile beaming up from his open casket. He was alive in the room, through the way he made his loved ones feel, even after he was gone. And in a way I felt lighter that evening, exiting the humid funeral home into a blast of cool Spring air, for having seen Viejo again for who he was, for who he would continue to be after his passing, through his presence that would live on through his loved ones.

***

Disease robs us of many things—time, comfort, energy—but perhaps most powerfully, it can rob us of our identities. It whittles away fat pads and warps facial expressions with anxious wrinkles. It drains the color from our skin, the strength from our muscles, the resilience from our bones. We speak often in Medicine about the need to see our patients not as their disease, but as human beings, and I see this good behavior modeled by colleagues on a daily basis; we regularly treat our patients and their families as though they were our own blood relatives.

But at the same time, as caretakers, we often lose sight of our own identities in the face of devastating disease, most often when we’re overwhelmed, when we’re trying to be strong despite exposure to repeated insults, when we encounter compounded losses that force us to put up walls and protect ourselves from falling apart entirely. Creating these distances—an understandable mechanism of self-preservation—can provide safety in the short term, but over time results in us standing farther apart from one another, our colleagues, our patients, and even our own families.

Maryann taught me a crucial lesson during that rotation as a sub-intern, about the power of human connection to heal us even in the moments when we feel least capable of facing each other. She taught me to always try and see people for how they’re really feeling, and to be self-aware of my emotions, not in order to compartmentalize them away, but to share them with colleagues who may be feeling similarly. She taught me to be strong for families, but also to empathize with them, to honor their suffering by acknowledging it and even experiencing it together. She taught me to transform those inevitable demons—pain, sorrow, and distress—from spikes that divide us into bonds that unite us, in a therapeutic partnership. If we can learn to practice Medicine this way—by facing challenges with connection, rather than isolation—we can more effectively bring healing to our patients and to their families, and to ourselves, as well.

***

Six months after Viejo passed, I found myself back on his floor, now a rookie resident physician, finally with the heavy letters “M.D.” behind my name, very much feeling the weight of the responsibility attached. I meandered into Viejo’s old room to meet my newest patient—a drug user raging on a PCP high, waving his fists and screaming obscenities to no one in particular—and I smiled to think that even with such a drastically different diagnosis within these walls, this still felt like Viejo’s room to me. The corner where his wife slept overnight, the counter where she’d pile up the food he never had the appetite to finish, the chair by the bedside into which both of his grandchildren would squeeze and keep him company.

As I retreated into the hallway, I saw Maryann and waved hello. “Are you ready, Doc?” she asked, playfully. I widened my eyes to signal my first day jitters, and she smiled back. “It’s OK,” she assured me. “Just remember to be yourself.”

 

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