My Epiphany

November 17, 2006

It only took a moment to realize that something's changed you forever.

Three patients-make that four-and 20 seconds brought me a fuller realization of what it means to be a physician than all the hours I spent in classrooms. Let me tell you about them and the day of my epiphany.

Frank was a middle-aged gentleman with a history of behavioral problems. His outbursts and unpredictability resulted from a motorcycle accident 10 years earlier. Since that time, he'd struggled with seizures, anger, left-sided weakness, and speech impediments. He'd been in and out of our busy inpatient medicine service many times over a period of months. This time he was admitted for aspiration pneumonia; I shuddered as I saw him again, recalling what it was like to care for him.

This time, however, Frank's behavior was different-less belligerent but more erratic. We quickly determined that he was in septic shock. I called Frank's sister, his spokesperson, and explained that he'd been readmitted and was in critical condition. I also had to reconfirm her desire for him to be on a ventilator as he was becoming increasingly distressed. Her voice dropped, sounding obviously concerned but also exhausted; she, too, was tired of taking care of Frank. She agreed, "Yeah, I guess we better do it." She clearly lacked the confidence I'd hoped to hear.

Although we succeeded in placing Pablo on the ventilator, I had grave doubts about our actions. When his son entered the ICU, he came close to me and, in a diminutive, fear-filled voice, asked, "I did the right thing, didn't I?" His usual stoic and strong face looked like a child needing reassurance and he was obviously holding back tears. I tried to comfort him and said, "At least it will give us an opportunity to determine what's wrong and if it's fixable." It was the best I could do.

Amanda, an 18-year-old who'd been admitted to deliver her baby, insisted on a C-section, despite our discussion of risks and alternatives. She'd heard from family members that a C-section was better than vaginal birth. After a discussion with our obstetrics faculty, we agreed to perform the operation and, fortunately, it went well.

The following day, Pablo had improved enough to be extubated; he whispered to me in his barely audible, hoarse voice, "Thanks for saving my life," and smiled his crooked smile. Despite the pulmonolgist's consult, we didn't have any more answers as to why his right lung had collapsed, but he was better, and he and his son were extremely appreciative.

Continuing on rounds, I came to Frank; he was on drotrecogin alfa (activated), Levophed, mechanical ventilation, and antibiotics, but he wasn't making much improvement.

Next I went to see Amanda's new little boy. It was during these 20 seconds that everything became clear.

As I looked at his day-old body, so clean, soft, and peaceful, I was overwhelmed with the complexities of what could go wrong. There are libraries of books describing the adaptation and destruction of this infant's body. What will life offer him? Who will take care of him, speak for him when he finally loses his voice? Will they know how precious he looked this morning? Which diagnoses may at some point be made? What accidents will injure him? How can we possibly understand the human body and what will cure it? There are simply too many mysteries.

Amanda's baby's first insult came by my hand with his circumcision. I'd done many of them before, but this was the first time it struck me as a violation. It hit me that I'd begun the processes of scarring, disease, and, most of all, the possible complications of medical care, just as I'd done with his teenage mother.

In our hospital, the ICU is 30 feet from the maternity ward and the well-baby nursery. I've often been amazed at the juxtaposition of disparate, extreme emotions in one hallway . . . tears of joy and sorrow intermingled . . . the start and end of life entwined in all its forms.

Yes, that day, it really hit me. There was Frank, with his 54-year-old body and all its insults; Pablo, who lived another day, only to wait for his lung to collapse again; Amanda, who electively underwent a C-section; and, her brand-new baby boy.

All of them had expectations that my knowledge of medicine would make them and their lives better. But I had to admit to myself that I was deficient in both confidence and knowledge. "I hope this gets better," I mumbled to myself with a new appreciation of the scope of medicine and all of its unknowns.

With this revelation and an acceptance of my lack of knowledge and control, I felt an unexpected sense of peacefulness and security. While I'd reconciled myself to the fact that there was much I didn't know and may never know, I moved on in the belief that at least learning and growing would advance with each passing day.