To the Men Who Told Me So Much, without Words ^[*]

There will always be those patients who stick with you. There will be the patients who you really connect with, those who show you a new perspective, or those who seem to view the world through a completely different lens. There will be those who you feel you have let down, or those who you are inspired by. Then there will be those who compel you to stop, take a step back, and reevaluate the way you interact. There will be patients who make you question your desire to be a doctor, and those who reaffirm it, over and over again.

For a medical student, almost every patient you meet stays with you. You, as a blank sheet of paper, are marked by the ink of every interaction. With so few experiences, each pen-stroke stands out strongly against the stark white background of naivety. With more experience, with each patient you meet, the pen strokes enhance the silhouette, drawing you as a doctor. Sometimes, these strokes will thicken lines that are already there. But sometimes, new lines will be drawn, creating a new part of your clinical self, or highlighting something that was previously too faint to be noticed.

For me, the pen strokes of two particular patients stand out, embossed clearly against my limited experience. These patients helped me to reflect upon my role as a medical student and further defined the image of who I want to be. As they slipped away from life, I felt powerless. I thought about my very limited skill set, not yet honed by hours of clinical practice. I thought about how I could be present, help out, and learn, without feeling like an intruder on these raw and terrifying moments. Both patients ignited my desire to be as useful as possible, so that their final days, hours, or minutes were exactly as they wanted them to be. I suspect none of this is particularly unusual. Thoughts of this nature are exactly what drive us to develop as doctors. What is different about these patients, however, is that I spoke with neither of them. Moreover, what is particularly remarkable about the second patient is that I never actually met him.

I should go back to the beginning to really set the scene. In our six-year medical course, the first three years are heavily theory based. We learn clinical skills and interact with ‘patients’, but these patients are primarily kind volunteers from the community. They give up their time to sit patiently while nervous medical students fumble with stethoscopes and try to remember the correct technique for lung percussion. In the relative safety of tutorial rooms, we take a history and do an exam. Surrounded by our colleagues, and under the watchful eye of our tutor, we take steps towards doctorhood. We do confront some pretty challenging emotions. It is extremely valuable to learn of the personal realities of ill health and the effects on each individual’s life. It is very real. But these are patients who have often lived with their illnesses for years. They have had time to process their emotions, adapt, and usually, are no longer struggling to confront the shock and reality of ill health. Eventually, in our second year, we have a six-week placement at a rest home. This is our first opportunity to really interact with patients in the community. This is where I met Johnny.

At the rest home, our job was to walk around and assist the carers when needed. We helped with meals, showered residents, and chatted as we helped them to get ready for bed. But there was one resident who never took part in the hustle and bustle of the evening routine. His door, adorned with the name ‘Johnny Hamilton’, was always open. Michelle, a carer at the rest home, told me that they left the door open so he would feel connected to things going on around him. Beyond the door was a man who appeared to be no more than a human shell. Johnny lay there, eyes open, staring at the ceiling. For my first few weeks, I never saw him move. In the staff office was a sign that read, “This rest home has a no resuscitation policy”. It served as a heavy reminder that, for some residents, this is where they came to die.

Taped to Johnny’s door was a photograph. Dwarfed by a muscle-bound All Black rugby player, Johnny sat, with a stoic smile. Although his hunched shoulders and drawn face hinted at his frailty, he held himself in such a way that suggested a typical, staunch, Southern Man mentality. I wondered how long ago the picture had been taken. The man lying beyond the door had little resemblance to this smiling Johnny.

One evening, Michelle, exhausted as she neared the end of her shift, decided that I should help as she cleaned and fed Johnny. So I followed her and took my first steps through that door, into Johnny’s room. It was bare except for a few boxes of medication, a drip, and a hospital bed. In that bed, lay Johnny, his muscles eaten away by sickness. His knee, the widest part of his leg, looked unnatural as it rested above the bed sheets. His skin was stretched taut over the underlying bones. His feet and ankles were swathed in bandages. Michelle told me this was to minimise the risk of pressure sores by evenly distributing his weight. Otherwise, the weight of his legs would bear down on the sharp ridges of bone that jutted through his skin. Johnny’s body stretched the length of the bed. I knew, if standing, that he would tower over me. But I knew his legs would not support his emaciated frame. I wondered when his feet had last touched the ground.

As Michelle went about getting things ready to clean Johnny, she spoke to him, “This is Claudia, she’s a medical student, she’s going to help us out a bit today”. “Hi Johnny,” I said, “I’m here on a placement, just helping out today”. I did not know whether he had heard me, or whether he could understand what I was saying, as he did not react at all. I saw how easy it could be to depersonalize care with an unresponsive patient, to treat them as a series of numbers and clinical signs. What are their electrolytes like? How about their GCS score?

I moved into Johnny’s line of sight as I spoke so that he could see who I was, again unsure of whether or not my image would register with him. As Michelle showed me the ropes, she spoke to Johnny about what she was doing, and why she was doing it, but also chatted about the weather and The Game. From the picture on the door, and Michelle’s talk, I gathered that Johnny was a rugby fan. I wondered what sort of man Johnny was, what he had done with his life. With no way to converse with Johnny, and no family members to tell me, the picture gave an infinitesimally small insight into his 80-plus years of life. As Michelle talked about rugby players and scrums and tries, I realised something that up until that point I had failed to appreciate: although doctors may be concerned with the numbers and clinical signs, the patient does not share this tunnel vision. When they get sick, they do not automatically lose all of their past experiences, their personality. Johnny was not any less of the person he had once been. In medical notes, you write down the information that seems relevant: the past medical history, the drugs, the height and the weight. On his deathbed, did it really matter how much Johnny weighed? The day-to-day stuff, the essence of the person, that is what is important. It should not have been such a jarring realisation. What did I think happened to the mind of people in Johnny’s position?

As I stood there, talking with Michelle and talking to Johnny, I was uneasy. Would he view me as an unwelcome intruder in his time of extreme vulnerability? Or was he delirious enough that he had no real connection with reality?

Michelle gently syringed some morphine into Johnny’s open mouth. She called it his, “happy water”. Johnny reacted little to this interaction, but something in his eyes told me that he understood what was going on. Johnny closed his mouth slightly as Michelle helped him to drink some Ensure, a meal replacement drink. I wondered if he was often hungry or thirsty. I imagined he would not be able to do much about it if he was. This was the first time I had felt powerless to help a patient.

Michelle asked me to take hold of the sheet that Johnny lay on, so she could shift him up the bed. As we started to move him, he suddenly responded with an energy that did not seem possible for someone so weak and unresponsive only moments ago. “No, stop it, it hurts, no. No.” There was no weight behind his words, only air rasping out of his lungs. Yet his words sunk to the pit of my stomach. I imagined how much energy it took for Johnny to rasp that, a man who had barely blinked. Again, I was confronted with the inadequacy of my skills. All of the medical knowledge in the world was inconsequential. He was in pain, he was dying, and that was something I could not fix. All I could do was hold his hand and gently try to reassure him that it was okay. So I held his hand, not wanting to crush his delicate fingers, but with a reassuring firmness. I tried to speak with confidence in my voice. “It’s okay Johnny, we’re just moving you so you don’t get sores, so that you can be clean. It’s okay. It’s okay. It’s okay.” Was it okay? No. He was dying. He was in pain. I let go of his hand briefly to help Michelle as she placed another incontinence pad under Johnny. I wondered if a New Zealand bloke such as Johnny would object to having his hand held. New Zealand men are stereotyped as being tough, staunch, and very reserved with their emotions. I cannot think of a time when I have seen my father cry.

What happened next still resonates strongly with me. As I was helping to rearrange the sheets, Johnny’s hand rose from where I had been holding it moments before, and searched for mine. He moved painfully slowly, but up, away from the bed, towards my hand. As soon as the sheets were straight, I re-grasped his hand, and he relaxed his arm back down onto the bed. Then I just stood there, as Michelle finished re-bandaging his legs and rearranging his blanket, holding his hand. Two weeks later, when I was away from University on my mid-semester break, Johnny died.

I do not know if Johnny knew who I was, or why I was there. He may have taken in everything that was said to him, without the energy to acknowledge it, or taken in nothing at all. I realise now that it does not really matter. Johnny showed me the power of human contact. No one in medical school talks to us about holding a patient’s hand. I did not have any drugs that I could offer him, or any great skills to improve his condition. With my medical knowledge in its infancy, I truly thought that I could do nothing. Johnny taught me that although I felt powerless to help, medical knowledge and expertise were not what he needed.

Almost a full year later, in my third year of medical school, another patient would leave his mark. I had travelled by car, 13 hours north, to a small New Zealand town. Our medical class had been split up into small groups and sent out across New Zealand to experience rural healthcare. For my group, the much-anticipated highlight of our trip was to be a 5 hour shift with the local ambulance service.

Though none of us wished ill on anyone in the small town, we each hoped to attend an emergency, a life-or-death situation. Having inhabited the sheltered Land of Medical Theory for most of our training, none of us had interacted with real, live patients, in real, live emergencies. Our only foray into ‘real’ medicine had been our rest home placement the year before, when I had met Johnny. In my experience, not being able to put a face to words like ‘cyanotic’, ‘asystolic’ and ‘myocardial infarction’ really voids them of emotion. In Medical Theory Land, it is easy to disconnect from the person attached to those numbers, signs and symptoms.

On the morning of my shift I turned up at 7 am, having walked there through the empty streets of the small town. The stark lights of the ambulance centre were in great contrast to the twilight of early morning outside. The staff, already in their fluorescent yellow vests, passed around plunger coffee, gearing up for another day. As I was handed a pager and had the protocols explained to me, I became more and more excited about the things I might see. I longed for the pager to go off, for us to leap into the ambulance, and for the sirens to blare as we sped off to an emergency. On the previous day’s shift, my classmate had only experienced low urgency calls – a couple of hospital transfers and a trip to the helicopter pad to drop off supplies. I hoped to have a more exciting day than her. I wanted to see things we had learnt about, to put my knowledge into practice. I wanted to return to our backpackers that night, full of stories of all the thrilling things I had seen and learnt.

I sat in the staff room in anticipation of what the day might bring. I did not have to wait long. Within 20 minutes of arriving, my pager went off. It was a ‘code purple’, the highest priority call. I could not believe my luck. The patient was 60 kilometers away. I rushed to take my seat in the ambulance as the automatic door of the station started to open. I made sure the seatbelt was firmly clicked into place and braced myself with one foot against the wall of the ambulance and one foot against a leg of the stretcher. I was careful not to hit my head on the ECG machine that rested on a shelf above me. The paramedic filled me in as information came in through the radio. The patient had gone into cardiac arrest, and was reportedly very cyanotic. I thought about atherosclerosis, ischaemia and shoulder-tip pain. I thought about platelet aggregation, oxygen saturation and heart contractility. GTN, MONA, CABG. What was his blood pressure like?

Through crackling static on the radio, I heard more information.

His wife had discovered him, minutes before. He was slumped in a chair. She did not have the strength to move him. As we streaked through the streets of the town and off into the rural area, the radio informant added something else: “Wife very distressed”.

Oh.

As I sat in the back of the ambulance, trying to prevent myself flying off the seat as the sirens blared and we sped around corners, I felt the blood drain from my face. “Wife very distressed”. I thought about her, waiting, waiting, and crying, longing for the ambulance to arrive, and for the paramedics to tell her that everything would be okay. I wondered what I should do, or say, when we arrived. Would she even be in a position to have a coherent conversation? Even with my limited experience, no one needed to tell me what the prognosis was, never mind the fact that he was 60 kilometers away. I knew the nausea that I was feeling was not solely due to the unpredictable motion of the ambulance. Part of it was due to how unprepared, once again, I felt, and part of it due to how disconnected I had been. “Wife very distressed”. I clenched my teeth and stared at the road out the back of the ambulance. Do. Not. Cry. Anything that directed attention away from the 2 people in greatest need, the man and his wife, would be completely unprofessional. I swallowed hard and kept my teeth clenched.

Soon after, more voices projected through the static on the radio, and we were stood down. Did that mean he did not make it? I did not need to ask the paramedics. I had little time to absorb things as we turned and sped off to a new call out, a ‘code red’, a suspected myocardial infarct.

Later, we met up with a group of students who had been placed in a nearby town, and we went rock-climbing. While I was up on the rock wall, other students started talking about their placements on the ambulance. Again, people exchanged brash sentiments about the excitement of an emergency, and exclamations of jealousy at the things others had seen. It turned out that the girl belaying me had also been on a shift with a ‘code purple’. “Wow, cool,” was my automatic response. “Not really,” she said. I was immediately knocked from my medical student bubble, and frustrated that, again, I could be so disconnected from everything. All I could reply was, “Oh, yeah, not really” as she let out the rope and lowered me to the ground. It turned out that she had been in the ambulance that had reached my code purple, and his wife, first.

Intrinsically, I understand the excitement of seeing things that we have learnt about in class, being able to put theory into action, and thriving on the adrenaline rush. One thing that makes for a good student is a thirst for knowledge. It is interesting. This interest is part of what keeps us here, what drives us to study. It fuels the late nights and the early mornings, and those days when you just want to be outside in the sun. I also understand the protective mechanism of being able to disconnect from the things you see. I imagine, working in such a high-stakes area, connecting too much with each patient and their family would lead to burnout, and a rollercoaster of emotion every day. Equally, when a person, or a person’s family, is having perhaps the most frightening experience of their life, the adjective to use is never, “cool”.

I am appreciative that my classmate could extract herself from the bravado and highlight the human context of our experience. They say you cannot teach common sense, and I wonder whether matters of empathy are similar. I do not know whether it is something that should be explicitly talked about in medical school. There is something to be said for experiencing things yourself, feeling things for yourself. The man and his wife that day taught me about the importance of staying connected to the person, the importance of staying human.

As I progress through medical school and develop into the doctor I want to be, I hope I will remain sensitive to each interaction. I hope that even after I feel strong and confident in my image, I will have space for new lines to be drawn, for a new perspective. I thank Johnny for showing me that the little things, the human things, count, and that we should not let textbook knowledge get in the way of being human. I thank him for reminding me not to let stereotypes dictate my interactions, and to let each patient guide me in their treatment. I thank the man from the small town, and his wife, for reminding me to stay connected to the emotion, and to keep that human perspective on health. I respect each patient and the lines that they draw, though I understand that art is subjective, and that there is no perfect ‘image’ for a doctor. Nevertheless, patient-by-patient, my silhouette is becoming bolder.

^* Names have been changed for confi dentiality.