Patient is a demented, chronically ill elderly male lying in bed attached to a ventilator, appearing anything but his stated age. Contracted in a fetal position, huddled under the bed sheet with only his bald head and wrinkled skin showing, he alternately resembles a centenarian or a newborn child—someone very much at the brink of life.
Mental Status Exam
Patient awake and alert, but severely cognitively impaired. Completely nonverbal and does not repeat or respond to commands. He looks observers in the eye, but he does not recognize faces and generally remains expressionless. On occasion, though, he spontaneously breaks into a beaming, ear-to-ear toothless smile that always surprises me, and at which I cannot help but sheepishly smile back. The entire room seems to light up, if only briefly, and even the doctors grin at the unexpected sight. Still, the smile feels vacant and lacking in underlying purpose. One of the doctors remarked to me that dementia sometimes resembles the normal development of a human being in reverse, as abilities are often progressively lost roughly in the order that they were first gained. Infants learn to smile at only two months of age. That developmental milestone is so important because smiling is such a distinctly human behavior. Although it is merely a reflexive response initially, a smile is an infant’s earliest social skill, a sign of his or her underlying humanity taking root. It is good to know that this patient will continue to smile for a while longer, but I cannot avoid thinking that, when that smile also disappears—as it inevitably will—dementia will have finally deprived him of even the most basic of shared human experiences.
All four extremities are tonically flexed and held tightly against his body. Even simple procedures such as drawing blood become difficult. He does not withdraw from pain. However, occasionally he appears to react by moving his head from side-to-side, as if shaking his head no. At other times he simply watches me as I perform the arterial stick. His eyebrows are furrowed and his eyes seem to water slightly, but he still does not he make any noise. In some ways, it is easier to do these kinds of painful procedures on patients who are very vocal—who talk, cry, or even yell at you to bear the pain. It is reassuring to hear them release some of their fear and provide themselves with a small measure of relief.
But this patient has no voice. Whatever he feels is locked silently inside of him, and so one feels palpable tension when looking at his seemingly tearful countenance, as if watching a brimming dam about to burst. To avoid his gaze, I usually keep my head down and focus on my work. But, on some days, I spend half an hour fruitlessly subjecting him to repeated, painful sticks, unable to adjust to his contracted posture, until finally I find myself looking up and irrationally resenting him for causing so much difficulty. This knee-jerk response is an immature defense mechanism, I know, but it comes from a sense of doubt. Facing the tangible evidence of my limited skills and self-confidence as a medical student is a reality I had hoped to avoid for a little while longer.
Pupils equal and reactive to light. His eyes are opened wide and colored wonderfully bright blue with the slightest hint of gray at the margins of the irises. There is significant temporal wasting bilaterally, which further accentuates the prominence of his eyes. While the rest of his body seems to have melted away, his eyes twinkle, and when one looks into them, one can almost imagine his face as it was when he was a young man.
Some crackles at the lung bases bilaterally. Scattered rhonchi heard throughout all lung fields. Every so often the patient’s throat gurgles softly as the ventilator operates. In the past I have accidentally dislodged the respiratory tube from its mooring in his neck after trying to examine him with the clumsy haste of a typical medical student. After hurriedly reattaching it, I found my hands were trembling. The fragility of the whole apparatus is startling, and it unsettles me how wholly dependent on it he is.
No masses, tenderness, rebound, guarding, or distension. A PEG tube feeds appallingly white nutrition directly into his abdomen. It suddenly occurs to me that he will never again experience the simple joy of eating: to taste, to chew, to swallow. Even the act of drinking from a glass of cool water is beyond him now.
Patient has no bladder or bowel control and is catheterized and diapered. Because of his condition, he is extremely malodorous, enough to make me pause and catch my breath before I lean forward. As I draw his blood, a worry emerges from the back of my mind that the odor might cling to me for the rest of the day, that it will follow me as I meet with my classmates and instructors. This concern is so obviously superficial in nature that it is appalling. Soon I have a difficult time deciding which is more offensive, the smell in the patient’s room or this absent-minded preoccupation.
Examination is limited by the patient’s contracted posture. Stage III pressure ulcers on the patient’s right thigh and left ankle. Stage IV pressure ulcer on the patient’s left leg. With a steel probe I can feel the blunt end of the instrument pushing past the necrotic soft tissue and striking the underlying bone, which is a truly unnerving sensation. Currently, the ulcerations are adequately dressed and the sites appear clean and dry, which is a relief. When uncovered the sight of these ulcers is not just disturbing but disheartening, simply because it is difficult to imagine how these large areas of damaged soft tissue could ever be repaired. I ask myself, how will this patient ever get better?
This is a 63 year-old male with a history of Alzheimer’s dementia, hypertension, hyperlipidemia, and previous stroke who was admitted with multiple stage III-IV decubitus ulcers on his trunk and lower extremities bilaterally.
Before beginning our rotations in June, we third-year medical students were often told that we would always remember every patient we helped to take care of. In my experience, this prediction has come true. Patients are memorable because each one seems to teach a new lesson. In our preclinical years we had been lectured endlessly about medications prescribed for congestive heart failure, but it was only after I followed a 66-year-old homeless man with CHF for three weeks, watching him gasp for air as he shuffled to the bathroom, that I finally understood how challenging it was to treat someone with advanced heart failure. It was only after talking with our 49-year-old immigrant with end-stage ovarian cancer, who admitted to us that she was facing violence at home, confided in us how scared she was and asked us to “help me stay strong,” that I understood that a doctor’s ability and obligation to help extended beyond laboratory tests and medications.
When we were asked to write about a patient encounter at the end of our medicine rotation, I naturally thought of patients like these at first—patients who were memorable because my experiences with them seemed to represent a step forward in my professional development in a very tangible and recognizable way. Instead I now find myself writing about Mr. L, described above, who at first glance did not seem an ideal patient to write about at all. His diagnosis was simple enough and management was relatively straightforward: antibiotics, debridement, supportive therapy. Without the ability to converse, it was difficult to piece together much of his story or develop a personal connection with him. And so my encounter with him does not form a neat vignette, unlike the other patients I followed. I do vividly recall his appearance, and I do remember how confusing it was to see him every day—to feel alternately frustrated and pitying, hopeful and helpless, disgusted and self-reproachful. But no clear unifying theme emerges to bring closure to this conflicting assortment and abundance of feeling. I think that despite this, or more likely because of it, Mr. L stands out in my mind more than any other.
I hope one day I can fashion those thoughts into a coherent narrative, some satisfying story with broader significance. Until I can, I think it means something simply to be able to describe what Mr. L looked like, how he behaved, the expression on his face, and the emotional reactions he evoked in his caregivers. It is even strangely therapeutic to accept that an encounter with a patient may affect us in ways we may not be able to fully appreciate immediately. For now, I know I will not forget his tearful eyes or his silent smile. For now, this is enough.
John Hwang is now a 4th year medical student at NYU School of Medicine