A Hand to Hold

DING DING DING! I fumble around for my phone in the darkness, frantically attempting to turn off my alarm before waking the rest of my sleeping family. The screen lights up. 5:23 AM – the latest possible time I determined I could wake up to make it to the hospital on time. I proceed through my morning routine on auto-pilot, and before I know it, I’m sitting down in the medical student room at the hospital. I look down. 6:30 AM exactly. Perfect timing. I smile to myself and take another swig of my 40 oz coffee (quickly replacing my mask, of course).  As with every previous day on my internal medicine rotation, I planned to do a quick chart-check before pre-rounding on the patients I had admitted the previous days. I opened my first chart and began scanning the notes from overnight and noting new labs. Everything was looking up for one of my patients. His labs were improving. Consultants were signing off. All he needed was a discharge plan and he would be up and out of here tomorrow, if not later today. Wonderful!

I clicked out of his chart and opened up the chart of the patient I had admitted the previous evening, around 7 PM. She was an 89-year-old woman who was presenting for evaluation of a week of chest and left arm pain. Her interview and exam the night before had taken longer than my other patient’s – nearly two hours. It was harder, too. This was because, on top of her chief complaint, she was having difficulty controlling her bladder and experiencing frequent episodes of dysuria that triggered nausea and vomiting. With urine cultures pending and empiric antibiotics and bladder anesthetics administered, there was little to do but wait for the medications to kick in. But, until then, every episode of dysuria was torture. She would cry out in pain between dry heaving. She would beg me to give her “something to just end it all already.” Holding the plastic vomit bag in front of her, I remember looking desperately around the empty room for something else I could do to help, something besides a warm hand to hold and reassuring words that I could give her for comfort. There was nothing.

To make matters worse, she was completely alone. Minnesota was experiencing its peak incidence of COVID-19, and guests were no longer allowed in the hospital. There was nothing I could do except wipe the corners of the mouth and hold her hand until the episodes slowed, and she could finally fall asleep. I remember feeling relieved as I tip-toed out of her room to update the nurse and go finish her H&P. After reviewing her newest labs, I attempted to write a plan for the next few days. She had signs of a missed MI, a new UTI, and a likely heart failure exacerbation. I confirmed the plan with the resident and attending and headed home for the night. I hoped that she would be much more comfortable when I saw her in the morning as the UTI resolved.

But when I opened the notes page of her EMR that next morning in the medical student room, something didn’t look right. Instead of the usual 5-10 nursing, lab, and consult notes, there was only one. A death note. As I focused in on those words, it was as if the rest of the world fell away. I could no longer see the coffee on the desk next to the computer. I could no longer hear the neighboring students chatting about what they watched on TV last night. I clicked on the note.

“Patient went into VT last night during a lab draw. Patient was DNR/DNI. MD paged and pronounced at 9:30 PM.”

Calm down. She lived a long life. Death is natural. At least it was fast. At least it was painless. Deep breaths.

I attempted to calm myself down with reassurances and deep breathing. But the emotions just kept coming. First, it was guilt. Did I miss something? Why didn’t I see this coming?

Second, it was sadness. She had been so kind and patient with me. Even when she was in terrible pain, she had never taken her frustration out on me. She did not deserve to die.

What hit me hardest, however, was the thought that maybe I had been the last person to ever hold her hand. This thought brought over a wave of emotions. On the one hand, I felt incredibly privileged. On the other hand, I felt immensely guilty that she had to share her last moments with me instead of being surrounded by her loving sons and many grandchildren. Who was I—a 24-year-old stranger with just a few months of clinical experience— to have such an honor? At what point did I become deserving of the intimacy she had shared with me during those final hours?

Since starting my clinical rotations, I’ve spent a lot of time reflecting on what it means to be a doctor. As I’ve progressed through medical school, I’ve always understood that the degree would come with far more than a pass to prescribe. I knew I would be responsible to provide my patients with evidence-based care and to teach them about their medical conditions in language they can understand. I also knew that medicine would bring a responsibility to advocate for the health and wellbeing of my patients and community both in and outside of the clinic.

But, as I held the hand of the dying woman that afternoon, my role was not to heal. There was no policy for which to advocate. And there certainly wasn’t anything I could teach. In that moment, my most important role as a soon-to-be doctor was simply to be human. The most meaningful care I could provide was the comfort of a warm hand and a humble respect for the dignity of my patient.

The field of medicine is fraught with obstacles that challenge the humanity of its providers. Between the emphasis on exam scores in medical school, the grueling hours of residency, the hierarchical culture that discourages speaking out, and the frustrating politics of hospital business, it often feels as if the healthcare system would prefer if we operated as robots – silently and efficiently. When I think about that afternoon in internal medicine, however, I am reminded that perhaps our most important role as a physician is to remain human.

When we become doctors, the world suddenly grants us an enormous trust. We must remember that such trust—the trust of another’s life— is one of life’s greatest privileges and must be continuously earned. Only by respecting the humanity of our patients can we identify and amend the historical trauma that the medical world has inflicted upon our communities of color. To be deserving of the trust placed in us by our patients from their first breaths to their final hours, we must first and foremost respect them as people and continuously challenge the policies and practices that strip them of human dignity. And only by respecting and reflecting upon our own humanity can we learn from our errors and develop the authentic connections necessary to fulfil our roles as healers, teachers, and learners.