When the Light Left

sundown

From my six week psychiatric inpatient rotation at a Veteran’s Hospital—February/March 1979

Sixty eight year old male catatonic with depression

He lies still, so very still under the sheet, eyes closed; the only clue that he is living is the slight rise and fall of his chest.  His face is skull like with bony prominences framing his sunken eyes, his facial bones standing out like shelves above the hollows of his cheeks, his hands lie skeletal next to an emaciated body.  He looks as if he is dying of cancer but without the smell of decay.  He rouses a little when touched, not at all when spoken to.  His eyes open only when it is demanded of him, and he focuses with difficulty.  His tongue is thick and dry, his whispered words mostly indecipherable, heard best by bending down low to the bed, holding an ear almost to his cracked lips.

He has stopped feeding himself, not caring about hunger pangs, not salivating at enticing aromas or enjoying the taste of beloved coffee.  His meals are fed through a beige rubber tube running through a hole in his abdominal wall emptying into his stomach, dripping a yeasty smelling concoction of thick white fluid full of calories.   He ‘eats’ without tasting and without caring.  His sedating antidepressant pills are crushed, pushed through the tube, oozing into him, deepening his sleep, but are designed to eventually wake him from his deep debilitating melancholy.

After two weeks of treatment and nutrition, his cheeks start to fill in, and his eyes are closed less often.  He watches people as they move around the room and he responds a little faster to questions and starts to look us in the eye.   He asks for coffee, then pudding and eventually he asks for steak.  By the third week he is sitting up in a chair, reading the paper.

After a month, he walks out of the hospital, 15 pounds heavier than when he was wheeled in.  His lips, no longer dried and cracking, have begun to smile again.

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Thirty two year old male rescued by the Coast Guard at 3 AM in the middle of the bay

As he shouts, his eyes dart, his voice breaks, his head tosses back and forth, his back arches and then collapses as he lies tethered to the gurney with leather restraints.  He writhes constantly, his arm and leg muscles flexing against the wrist and ankle bracelets.

“The angels are waiting!!  They’re calling me to come!! Can’t you hear them?  What’s wrong with you?   I’m Jesus Christ, King of Kings!!  Lord of Lords!!  If you don’t let me return to them, I can’t stop the destruction!”

He finally falls asleep by mid-morning after being given enough antipsychotic medication to kill a horse.  He sleeps uninterrupted for nine hours.  Then suddenly his eyes fly open, and he looks startled.

He glares at me.  “Where am I? How did I get here?”

“You are hospitalized in the VA psych ward after being picked up by the Coast Guard after swimming out into the bay in the middle of the night. You said you were trying to reach the angels.”

He turns his head away, his fists relaxing in the restraints, and begins to weep uncontrollably, the tears streaming down his face.

“Forgive them, Father, for they know not what they do.”

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Twenty two year old male with auditory and visual hallucinations

He seems serene, much more comfortable in his own skin when compared to the others on the ward. Walking up and down the long hallways alone, he is always in deep conversation. He takes turns talking, but more often is listening, nodding,  almost conspiratorial.

During a one-on-one session, he looks at me briefly, but his attention continues to be diverted, first watching an invisible something or someone enter the room, move from the door to the middle of the room, until finally, his eyes lock on an empty chair to my left.  I ask him what he sees next to me.

“Jesus wants you to know He loves you.”

It takes all my will power not to turn and look at the empty chair.

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Fifty four year old male with chronic paranoid schizophrenia

He has been disabled with psychiatric illness for thirty years, having his first psychotic break while serving in World War II.   His only time living outside of institutions has been spent sharing a home with his mother who is now in her eighties.  This hospitalization was precipitated by his increasing delusion that his mother is the devil and the voices in his head commanded that he kill her.  He had become increasingly agitated and angry, had threatened her with a knife, so she called the police, pleading with them not to arrest him, but to bring him to the hospital for medication adjustment.

His eyes have taken on the glassy staring look of the overmedicated psychotic, and he sits in the day room much of the day sleeping in a chair, drool dripping off his lower lip.  When awake he answers questions calmly and appropriately with no indication of the delusions or agitation that led to his hospitalization.  His mother visits him almost daily, bringing him his favorite foods from home which he gratefully accepts and eats with enthusiasm.   By the second week, he is able to take short passes to go home with her, spending a lunch time together and then returning to the ward for dinner and overnight.   By the third week, he is ready for discharge, his mother gratefully thanking the doctors for the improvement she sees in her son.  I watch them walk down the long hallway together to be let through the locked doors to freedom.

Two days later, a headline in the local paper:

“Veteran Beheads Elderly Mother”

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Forty five year old male — bipolar disorder with psychotic features

He has been on the ward for almost a year, his unique high pitched laughter heard easily from behind closed doors,  his eyes intense in his effort to conceal his struggles.  Trying to follow his line of thinking is challenging, as he talks quickly, with frequent brilliant off topic tangents, and at times he lapses into a “word salad” of almost nonsensical sentences.  Every day as I meet with him I become more confused about what is going on with him, and am unclear what is expected of me in my interactions with him.  He senses my discomfort and tries to ease my concern.

“Listen, this is not your problem to fix but I’m bipolar and regularly hear command voices and have intrusive thoughts.  My medication keeps me under good control.  But just tell me if you think I’m not making sense because I don’t always recognize it in myself.”

During my rotation, his tenuous tether to sanity is close to breaking.  He starts to listen more intently to the voices in his head, becoming frightened and anxious, often mumbling and murmuring under his breath as he goes about his day.

On this particular morning, all the patients are more anxious than usual, pacing and wringing their hands as the light outdoors slowly fades, with noon being transformed to an oddly shadowy dusk.  The street lights turn on automatically and cars are driving with headlights shining.  We stand at the windows in the hospital, watching the city become dark as night in the middle of the day.   The unstable patients are sure the world is ending and extra doses of medication are dispensed as needed while the light slowly returns to the streets outside.  Within an hour the sunlight is back, and all the patients are napping soundly.

The psychiatrist, now floridly psychotic, locks himself in his office and doesn’t respond to knocks on the door or calls on his desk phone.

Stressed by the recent homicide by one of his discharged patients, and identifying too closely with his patients due to his own mental illness,  he is overwhelmed by the eclipse.   The nurses call the hospital administrator who comes to the ward with two security guards.  They unlock the door and lead the psychiatrist off the ward.  We watch him leave, knowing he won’t be back.

It is as if the light left and only shadow remains.

total eclipse

A Loss of Innocence

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As a physician-in-training in the late 1970’s, I rotated among a variety of inner city public hospitals, learning clinical skills on patients who were grateful to have someone, anyone, care enough to take care of them. There were plenty of homeless street people who needed to be deloused before the “real” doctors would touch them, and there were the alcoholic diabetics whose gangrenous toes would self-amputate as I removed stinking socks. There were people with gun shot wounds and stabbings who had police officers posted at their doors and rape victims who were beaten and poisoned into submission and silence. Someone needed to touch them with compassion when their need was greatest.

As a 25 year old idealistic and naive student, I truly believed I could make a difference in the 6 weeks I spent in any particular hospital rotation. That proved far too grandiose and unrealistic, yet there were times I did make a difference, sometimes not so positive, in the few minutes I spent with a patient. As part of the training process, mistakes were inevitable. Lungs collapsed when putting in central lines, medications administered caused anaphylactic shock, pain and bleeding caused by spinal taps–each error creates a memory that never will allow such a mistake to occur again. It is the price of training a new doctor and the patient always–always– pays the price.

I was finishing my last on-call night on my obstetrical rotation at a large military hospital that served an army base. The hospital, built during WWII was a series of far flung one story bunker buildings connected by miles of hallways–if one part were bombed, the rest of the hospital could still function. The wing that contained the delivery rooms was factory medicine at its finest: a large ward of 20 beds for laboring and 5 delivery rooms which were often busy all at once, at all hours.  Some laboring mothers were married girls in their midteens whose husbands were stationed in the northwest, transplanting their young wives thousands of miles from their families and support systems. Their bittersweet labors haunted me: children delivering babies they had no idea how to begin to parent.

I had delivered 99 babies during my 6 week rotation. My supervising residents and the nurses on shift had kept me busy on that last day trying to get me to the *100th* delivery as a point of pride and bragging rights; I had already followed and delivered 4 women that night and had fallen exhausted into bed in the on call-room at 3 AM with no women currently in labor, hoping for two hours of sleep before getting up for morning rounds. Whether I reached the elusive *100* was immaterial to me at that moment.

I was shaken awake at 4:30 AM by a nurse saying I was needed right away. An 18 year old woman had arrived in labor only 30 minutes before and though it was her first baby, she was already pushing and ready to deliver. My 100th had arrived. The delivery room lights were blinding; I was barely coherent when I greeted this almost-mother and father as she pushed, with the baby’s head crowning. The nurses were bustling about doing all the preparation for the delivery:  setting up the heat lamps over the bassinet, getting the specimen pan for the placenta, readying suture materials for the episiotomy.

I noticed there were no actual doctors in the room so asked where the resident on call was.

What? Still in bed? Time to get him up! Delivery was imminent.

I knew the drill. Gown up, gloves on, sit between her propped up legs, stretch the vulva around the crowning head, thinning and stretching it with massaging fingers to try to avoid tears. I injected anesthetic into the perineum and with scissors cut the episiotomy to allow more room, a truly unnecessary but,  at the time, standard procedure in all too many deliveries. Amniotic fluid and blood dribbled out then splashed on my shoes and the sweet salty smell permeated everything. I was concentrating so hard on doing every step correctly, I didn’t think to notice whether the baby’s heart beat had been monitored with the doppler, or whether a resident had come into the room yet or not. The head crowned, and as I sucked out the baby’s mouth, I thought its face color looked dusky, so checked quickly for a cord around the neck, thinking it may be tight and compromising. No cord found, so the next push brought the baby out into my lap. Bluish purple, floppy, and not responding. I quickly clamped and cut the cord and rubbed the baby vigorously with a towel.

Nothing, no response, no movement, no breath. Nothing.  I rubbed harder.

A nurse swept in and grabbed the baby and ran over to the pediatric heat lamp and bed and started resuscitation.

Chaos ensued. The mother and father began to panic and cry, the pediatric and obstetrical residents came running, hair askew, eyes still sleepy, but suddenly shocked awake with the sight of a blue floppy baby.

I sat stunned, immobilized by what had just happened in the previous five minutes. I tried to review in my foggy mind what had gone wrong and realized at no time had I heard this baby’s heart beat from the time I entered the room. The nurses started answering questions fired at me by the residents, and no one could remember listening to the baby after the first check when they had arrived in active pushing labor some 30 minutes earlier. The heart beat was fine then, and because things happened so quickly, it had not been checked again. It was not an excuse, and it was not acceptable. It was a terrible terrible error. This baby had died sometime in the previous half hour. It was not apparent why until the placenta delivered in a rush of blood and it was obvious it had partially abrupted–prematurely separated from the uterine wall so the circulation to the baby had been compromised. Potentially, with continuous fetal monitoring, this would have been detected and the baby delivered in an emergency C section in time. Or perhaps not. The pediatric resident worked for another 20 minutes on the little lifeless baby.

The parents held each other, sobbing, while I sewed up the episiotomy. I had no idea what to say,  mortified and helpless as a witness and perpetrator of such agony. I tried saying I was so sorry, so sad they lost their baby, felt so badly we had not known sooner. There was nothing that could possibly comfort them or relieve their horrible loss or the freshness of their raw grief.

And of course they had no words of comfort for my own anguish.

Later, in another room, my supervising resident made me practice intubating the limp little body so I’d know how to do it on something other than a mannequin. I couldn’t see the vocal cords through my tears but did what I was told, as I always did.

I cried in the bathroom, a sad exhausted selfish weeping. Instead of achieving that “perfect” 100, I learned something far more important: without constant vigilance, and even with it,  tragedy intervenes in life unexpectedly without regard to age or status or wishes or desires. I went on as a family physician to deliver a few hundred babies during my career,  never forgetting the baby that might have had a chance, if only born at a hospital with adequately trained well rested staff without a med student trying to reach a meaningless goal.

This baby should now be in his 30’s with children of his own, his parents now proud and loving grandparents.

I wonder if I’ll meet him again — this little soul only a few minutes away from a full life — if I’m ever forgiven enough to share a piece of heaven with humanity’s millions of unborn babies who,  through intention or negligence,  never had opportunity to draw a breath.

Then, just maybe then, forgiveness will feel real and grace will flood the terrible void where, not for the first time nor the last,  guilt overwhelmed what innocence I had left.

snowonsnowdrops

 

 

Hitchhiking Right Out of the Classroom

His reputation was well known and all the medical students had heard the stories about Dr. Rosse. As the Anatomy Professor, his class would become the primary focus of student energy in the first year of medical school, with other classes seeming like so much background noise.

Dr. Rosse believed in active student participation in class, in the cadaver lab, on oral tests. He told us from the first day on: ” You will learn to THINK in this class like you’ve never thought before! Your patient’s lives depend on this. You will be prepared for my class each and every day, just as you must be prepared for whatever your patients will need from you.”

He was correct.

There were 110 of us in the lecture hall that first day, looking nervously at each other and at the empty podium down in front. We had been assigned three chapters in the anatomy textbook before Dr. Rosse’s first lecture and were expected to know the names of the bones and major blood vessels.

Dr. Rosse’s assignment for himself was to memorize our names and faces from a photo directory provided to him two days previously.

He began his lecture in the barely darkened room, running quickly through a carousel of slides of graphic photos and drawings of body parts. Within five minutes, he stopped and in his thick European accent, pointed at a student in the second row said: “Mr. Davis, can you tell me the name of this blood vessel on this slide?”

The student sat up startled, and sat silent, gathering his wits. Dr. Rosse looked pointedly at his wrist watch and started saying, “Drip. Drip. Drip.”  The student started to sweat.

“Drip, drip, drip, your patient is losing blood, Mr. Davis.”

The student, in a moment of enlightenment asked,” the inferior vena cava?” and Dr. Rosse said, “Very good, Mr. Davis!” and made a notation on the tablet on the podium in front of him.

The rest of our hearts immediately were in our throats, something that Dr. Rosse would later tell us was an anatomic impossibility, no matter how much it felt like it. There would be no dozing off, daydreaming or not preparing for this class.

My turn came the following week as he called out my name, his steely eyes fixed on only me. I got off fairly easy with a question from Dr. Rosse about the attachments for the extensor pollicis longus. I had memorized all the arm muscles the night before so was prepared.

“Yes, very good, Miss Polis.  Now tell me, if I were to fall off this podium right now, land on my outstretched arm and rupture my extensor pollicis longus, what would I not be able to do with my arm?”

I had no idea. I looked at him somewhat aghast. I thought I had done the necessary preparation to be ready for his questioning. My memorizing names and locations of muscles and tendons had only taken me so far. I had not really thought about the functionality of what I was learning and how it might be relevant to my future patients.

“Think now Miss Polis! This is not so very hard that you can’t THINK it out!”  Dr. Rosse demanded from the podium.

So I guessed. “Uh, you can’t grip?”

“Exactly wrong! Take a hike back to your study carrel, Miss Polis.  You have not prepared yourself well enough. Go back to your book, and with each muscle you memorize, you must feel it on yourself or your study partner and think about how it works. Your patient will thank you for that someday.”

I was mortified that day, but survived that anatomy class, survived six oral exams over the cadaver with Dr. Rosse, and although I didn’t get an A in his class, I was very relieved to get a B+. As a student, I had never been asked before to actually apply what I was learning to make it relevant to my future work. Dr. Rosse was right. I had learned to not just memorize, but to think.

And when I saw my first extensor pollicis longus rupture seven years later in my practice, I was absolutely confident of the diagnosis because my patient could not lift up his thumb when asked to act like he was hitchhiking.  And my patient did thank me.  Dr. Rosse was right again.