Internal M&M

Like the last two Mornings, The Intern parked his Laptop on Wheels at the Nursing Station and went into a nearby room to see Mr. B. And like the last two Mornings, Mr. B was there, lying in his hospital bed. The Intern looked him over. Some increased bruising on his right arm, maybe some increased bleeding in his gumline. The rest of him looked the same, save an IV sticking out from a long bone in his lower left leg. The Intern lifted the diaphragm of his stethoscope onto Mr. B's chest and heard nothing. This was a New Morning, and this was a New Finding. The Intern had expected it. A silence - really, a vacuum - had replaced once robust heart sounds.

Earlier That Morning, The Intern woke up, weary and maybe even a little defeated, after a Call Day that marched into the night. Like every Morning he reflexively checked his e-mail, and saw the Night Resident's message that Mr. B's heart stopped some time before daybreak. They couldn't resuscitate him. There was the jolt of shock and sadness, of course, but, for that one tiny slice of The Intern's cortex, a perverse affirmation, as well.

The Previous Morning, Mr. B greeted The Intern as always. "Hey doc, what's going on? How are you?" The Intern dutifully listened to his heart, his lungs, examined his eyes, mouth, fingernails and felt his abdomen. He felt for enlarged lymph nodes. Everything was fine like always, despite The Numbers telling him otherwise. Very low platelets, very high this, very low that. More Data forthcoming. Biopsy results pending. The difference between Mr. B in person, on exam, and Mr. B on The Computer was always jarring and troubling to The Intern. Something viscerally troubled him more on this day, however. He came to check in on Mr. B every two hours or so.

And so for the first part of Yesterday, Mr. B was just like he was on admission - well-appearing, kind, deferential, interested in talking about his family, and speaking seriously about an incipient scandal in college football. But later in the day, he seemed uncomfortable. "I don't know what's going on doc...I just don't feel right," he told The Intern. He pointed to his abdomen, just below his rib cage - "it hurts here. I’m sorry to keep bothering you." The Intern examined him, drew some Labs, looked over a Scan and then reassured him. "First of all, don’t apologize. I’m here to Take Care of you. And what’s going on, it's probably your pancreas. I'm going to give you some fluids, some pain medications. We’ll get an ultrasound. Don't eat anything, OK? Well, maybe you can have that milkshake over there. I'll turn a blind eye to that." A lame joke, a smile.

But The Intern was disturbed. Mr. B could not articulate what was wrong with him and The Intern knew him to be an articulate man. The Intern pushed what he recognized as an ominous feeling to the recesses of his brain, so that it occupied only a tiny slice of cortex, and pushed his Laptop on Wheels forward to see another patient who was very ill. He did, however, return to see Mr. B a few more times, and was reassured when he seemed a bit better. At eleven that night, The Intern saw Mr. B one final time before going home. "I'm great doc, thanks for everything! Go get some sleep!"

As he looked down at Mr. B on This Morning, The Intern's mind skipped through a slide set of images and thoughts, as if they were set to a random shuffle. He remembered, with some shame, how three days ago he was annoyed to be paged about a new admission late in the day, only to feel some form of joy when he connected with Mr. B during that first conversation. He thought about how Mr. B told him about the first time he met his wife, when she thought he was "some married jerk flirting with her," only to realize later that he was single and legit - "we've been together ever since." He wondered whether Mr. B's pancreatitis, chest pain and low platelets were all tied together by one of two catastrophic diseases, based on a discussion he had with The Consultants and The Attending the other day. He remembered what Mr. B said about his children, how they weren't wealthy but were doing jobs that they really liked and that that's what he’d always wanted for them. The Intern knew he'd tell his children the same thing someday.

He remembered how Mr. B kept talking about his family and his good fortune to have them in his life. He talked more about them Yesterday and The Intern wondered then if Mr. B somehow knew Yesterday itself that he would not see them ever again. He wondered if articulate people being unable to find words for their unease and distress was a poor prognostic sign.

And then he asked himself whether he could have done something differently. Whether he could have thought more about the medical mystery that was Mr. B instead of spending time running around writing for Eucerin cream and Imodium or rushing through tasks in order to go home at a reasonable hour. He wondered if Large Academic Hospital's Cadillac of a Differential Diagnosis distracted him from the few more obvious possibilities, the ones that may have mattered to fixate on. He wondered if he could have simply done better by knowing more and thinking faster. He wished that tiny slice of cortex that told him to be afraid did so more loudly and forcefully.

It was then that The Intern noticed The Tag on Mr. B's left big toe. He didn't bother to read what was written on it; he knew it served to identify, perhaps to differentiate Mr. B from others in The Morgue. The Intern looked elsewhere, with his gaze stopping at Mr. B's right hand, which lay there palm up, fingers open. The Intern thought he must have died like this, keeping his hand that way as if to ask to touch another person one last time before his exit. The Intern reached down and closed his fingers, rotated the hand inward. Mr. B's fingers were cold in a way that The Intern had never experienced. The Floor Nurse stared at The Intern, worried and puzzled. The Intern looked up at her, adjusted his Mask of Professionalism, and then left, rolling his Laptop on Wheels, Progress Notes in hand, ready to see his next patient and scribble down The Plan before Attending Rounds started.

A Senior Resident told him that every Resident has a Patient that dies like this and that it is part of the Doctor Experience. “You’ll be fine.” But The Intern knew that the questions, regrets, self-doubts, memories, and sorrows would all come back later. In a wave that would sweep him into a darker place. As if reflexively, he suddenly thought of the people he felt lucky to have in his own life, and reached into his pocket for his phone.