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Getting to Know Mr. G


The New Physician July-August 2004
“If you’ve finished your H&P on that last case, you’re done admitting for tonight. You should stop by Room 330, though. The patient has a pretty interesting rash,” my intern said.

I was a freshly scrubbed third-year, eight weeks into my clinical rotations and still getting used to my role. I had begun the second leg of my internal medicine rotation—this one at a managed-care hospital—and after four weeks at a Veterans Affairs hospital, I was eager to see something other than older, white males with three pages of medical histories.

I paused outside Room 330 to read the intern’s notes. Mr. G had come in complaining of chronic low back pain but was subsequently found to have a rash on both legs. I introduced myself. “Hi, my name is Grace, and I’m a medical student on the team that will be taking care of you. I understand you are having some back pain and a rash over your legs. Would you mind if I take a look?”

Mr. G was a thin, older man in his early 70s, with sparse white hair covering his head. “Why not?” he answered. “Everyone else has already. I don’t know why they’re all so interested in that rash, though. It’s my back that’s hurting me.”

I assured him we would do our best to take care of his back pain but we would also have to find out what was causing the rash. I did a thorough exam of his legs and, satisfied, covered Mr. G back up, telling him I would see him the next day.

The next morning he was complaining about his back to an older woman by his bed. “You must be Mrs. G,” I said.
“Yes, I am,” she said. She told me her husband had been discharged three weeks before from a skilled nursing facility and was doing fine until the rash developed several days ago.

I said I would try to get to the root of the problem. As I took Mr. G’s medical history, I realized his back pain had been the source of many hospital admissions. I inquired about incontinence, and he admitted he sometimes had difficulty “keeping it in.” An alarm bell went off in my head.

When my team rounded later that day, I dutifully reported the new findings on Mr. G. An MRI of the spine was the next logical step, I explained, to rule out the presence of cauda equina syndrome, a serious condition in which the spinal cord fibers are compressed, requiring immediate surgery.

Unfortunately, our hospital allowed only two inpatient MRIs a day. “How sure are you about this?” my attending asked.

“Fairly certain,” I said, though I regretted making such a big deal about it as soon as I said it. Neither my intern nor my resident seemed as excited as I was. Perhaps incontinence was more common than I had thought, and who was I to know when an MRI was necessary?

But they agreed, and we wrote the orders for Mr. G to have one later that day. “For educational purposes,” my resident said. Sure enough, the MRI came back negative for cauda equina syndrome, and I humbly realized that my medical education had taught me to be so alert to abnormalities, I had failed to recognize a condition’s normal variants.

During the next few days, we obtained a dermatology consult, experimented with pain medications and arranged for daily physical therapy. By this time I had grown quite fond of Mr. G and had taken him on as one of my patients so I could be more involved in his care. Because I was a student, I had the luxury of time and considered myself an ally of my patients.

Our morning pre-rounds always consisted of jokes and stories of his younger days when he played tenor sax in a jazz trio. He would wink at me as I entered the room, give me an update on his rash—which nearly disappeared—and grumble good naturedly when I asked him to sit forward so I could listen to him breathe.

By the end of the week, his rash— diagnosed as “idiopathic” (a term I now know we use when we don’t know the cause)—had cleared, and he was slowly progressing in his physical therapy sessions. He was ready to be discharged to a skilled nursing facility.

On the day of his transfer, I stopped by to say goodbye and wish him good luck. But hours later I learned Mr. G was still in the hospital. As he was being moved to a gurney, his oxygen saturation fell and his heart went into rapid atrial fibrillation, despite numerous medications.

From that point on, his medical course fluctuated not by the day but by the hour. His oxygen saturation levels continued to teeter in the low 90 percentiles. We supplemented oxygen through a nasal cannula, but more often than not, he would pull it off. His nurses and I tried numerous approaches: first setting an alarm on the pulse oximeter, then taping the cannula to his face. But these didn’t work either.

“You could write for restraints,” one of the nurses suggested. I cringed. It seemed inhumane, but we had exhausted nearly every possibility. Reluctantly, I asked my resident, who agreed it was the wisest thing to do and wrote the orders.

On some level, they worked beautifully. Now that he wasn’t able to pull off the nasal cannula, his oxygen levels stabilized, his mind cleared a little, and I was able to catch a glimpse of my old patient. By his ninth day in the hospital, he began to wink at me again. At the same time, though, it broke my heart to see him strapped to his bed all day.

By now, I was talking regularly with his wife and sons to update them on his progress. Although it was unusual for a medical student to be the family liaison, I believed it was the most natural thing to do, given the constant turnover of interns, residents and attendings on our team.

Near the end of his second week in the hospital, Mr. G’s creatinine levels started to rise, and despite our efforts to keep him well-hydrated, he continued to progress toward renal failure.

“It’s time to have a family meeting,” my resident said, and I understood her implication. “It’s just better if everyone has a clear idea what his condition is and how we should manage him.” We scheduled it for the following weekend.

When I returned the next Monday and asked what Mr. G’s family had decided, my attending surprised me by saying, “They said they wanted you to be present for that decision, since you were there from the beginning.” I was touched by their level of trust in me. It was the first time I had felt the true weight and privilege of caring for another person’s life.

At the same time, though, I felt helpless. Nothing seemed to alter the course of Mr. G’s illness, and I felt responsible that his condition was rapidly spiraling downward. During the three weeks he was in the hospital, I must have reviewed my notes dozens of times, trying to figure out where we failed. I couldn’t believe that someone who had come in with a simple complaint of back pain and had been ready for discharge one week later could now be facing comfort care. I also believed to some extent that the longer Mr. G stayed in the hospital, the worse off he was.

I asked Mrs. G how she was handling it all. She said she didn’t know what to do; she and her husband had been married for close to 50 years, and she felt like she should continue to push for him, even if he was no longer able to. At the same time, she didn’t think he would have chosen this for himself. She decided she needed more time, which I agreed was reasonable.

But two days later we heard a code called for a patient in Room 404—Mr. G’s room. “This is it,” I thought.
But it wasn’t. Despite all the insults hurled at his body, Mr. G still hung on. He was hardly conscious most of the time, unable to speak due to the mask on his face but still able to give a feeble wink. It was only after two more codes that his wife and sons said they realized his body had been through enough. The pain on Mrs. G’s face as she informed me of their decision spoke to her courage. We walked the family through the logistics of taking him off the ventilator.

After the nurse had removed the IV, turned off the machines and given Mr. G morphine, we left the room so the family could be together one last time. I didn’t know how long it would take for him to pass away; my attending said it could be 10 minutes to an hour, so when half an hour had passed, I knocked on the door.

One of his sons let me in, and I could see from the redness in his eyes that he had been crying. They had scattered rose petals all over their loved one’s body, and as I held Mr. G’s hand, I realized it was the first time I had ever seen a dead person. I noticed his cold, yellow, waxy skin. I was also aware how quiet the room was without the machines. But I hadn’t expected to feel the sense of peace that was present in the family and, to my surprise, myself.

Mrs. G hugged me, which I think brought more relief to me than it did to her. One of his sons showed me some pictures of Mr. G as a young army pilot with his plane, dressed up for his wedding, with his jazz trio, with his young family, and then as he celebrated his 65th birthday.

The hospital chaplain entered the room. “Would you like to join us in a prayer?” Although I wasn’t a religious person, I was grateful for the invitation. As we held hands, I realized Mr. G had been so much more than my patient. I had learned more about him from the pictures and thoughts his family shared with me than I had in the three weeks when he had been under my care. And I felt again a sense of gratitude to Mr. G and his family for allowing me to become a part of his life.
Grace Chen Yu is a family practice resident at San Jose Medical Center in San Jose, California.