In January of last year, the coagulation cascade was a source of trepidation. It was tedious to memorize the factors and co-factors, the intrinsic and extrinsic pathways, the PTs and PTTs. I drew the diagram countless times, my pencil connecting Roman numerals with lead-gray arrows, soft lines coalescing into a final common clot on the page. I drew it again.
I developed a special sense of consternation toward the clotting and bleeding disorders—immune thrombocytopenia, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura. They mystified me. I pictured platelets and thrombin and fibrin and von Willebrand factor rushing through blood vessels, circulating and sticking and swirling and releasing, catching hold of one another and letting go. Bleeding and clotting, producing and consuming.
We finished the month of MDTI, and I moved on. Brain and Behavior, Repro, Endo, GI, Cardio, Renal, Pulm. A whirlwind tour through the human body, system by system, streamlined in isolation. Words on a page, PowerPoint slides on a screen, 1.5x speed.
In January of this year, I walked into the hospital to begin the first rotation of my clerkship year: Internal Medicine. I made my way up to the fourth floor of Presby, a blend of apprehension and excitement (and three flights of stairs) pounding in my heart. After I met my team of residents and our attending, I asked who my first patient would be. “You can follow Ms. M,” the senior resident told me. “She’s here with DIC after bacteremia and septic shock in the MICU.”
The mental movie from MDTI began playing in my mind. DIC—Disseminated Intravascular Coagulation, simultaneous bleeding and clotting throughout the body. I imagined platelets rushing through blood vessels and sticking to walls, a systemic reaction to the inflammatory stressor of sepsis. “You can go say hello to her,” the resident told me, jolting me out of my trance. I nodded nervously and left the workroom to find Ms. M.
As I roamed the hospital halls, my mind wandered back to what I knew about DIC. I realized that while I had learned about DIC from lectures and PowerPoint slides, I appreciated nothing about what it meant for a patient. My feet stopped in front of Ms. M’s door. I took a deep breath and braced myself. Knock, knock. Two quick raps. “Come in,” she faintly replied, almost imperceptibly.
Ms. M lay in bed, covers pulled up to her chin, her head the only visible part of her. Drip, drip, drip. I glanced to the corner of the room—a bag of heparin trickled into her veins. “Hi, Ms. M,” I ventured cautiously. She looked at me in a daze. I gently began to ask about her hospital course as we had practiced with standardized patients. However, I quickly realized that she didn’t yet fully understand what had happened to her. “You had a bacterial infection in your blood, and it made you very sick,” I tried to explain. “Your body reacted to the stress with clotting and bleeding, and some of those clots have gone to your lungs and your feet.” Ms. M nodded slowly. “Mind if we take a look?” I asked.
When I pulled back the covers, my heart plummeted. Dark purple blotches coalesced up her arms and legs, evil in their lacy lure. Where IVs had entered her skin, deep red purpura spread outward, perniciously tracing the lines of livedo reticularis. I gently touched her legs, and she winced in pain. Her right foot was stone cold, unperfused. “It burns,” she moaned.
DIC—Disseminated Intravascular Coagulation. What had once been an esoteric concept, a theoretical condition, was now laid bare in front of me on the first day of my first inpatient rotation of medical school. Suddenly, it carried much more weight. I lightly pulled up the covers, being careful not to cause her pain as I hid her mottled skin beneath the crisp white sheets. “I’ll come back to visit again later,” I feebly concluded.
As the days progressed, the necrosis of Ms. M’s feet advanced. She began to cough up blood from the infarct in her lung. Her toes darkened and shriveled. One morning when I visited her before rounds, her mother and her daughter clung to one another at her bedside. “Is she going to lose her feet?” her 24-year-old daughter wept to me, tears spilling out from her eyes and tracing lines down her cheeks. I couldn’t help but recognize that Ms. M’s daughter and I were the same age. This was her family—her mother.
In the evenings at home, I kicked myself at how I had complained about DIC a year ago. What I had viewed as yet another condition on the list of those to study had suddenly become disturbingly real. The mental movie that had once helped me understand the condition now haunted me at night—the platelets, the bleeding, the clots. They raced through my dreams. I wondered how many other conditions I had reduced to a PowerPoint slide.
Throughout the rest of my Internal Medicine rotation, many illnesses that we had learned during Core 1 presented themselves in my patients. I heard my first murmur of aortic stenosis, pressed on my first ankles with pitting edema, ultrasounded my first heart with an ejection fraction of 15% and barely a squeeze on the screen. Everything that had been lifeless on paper had come to life in a person, in the most unsettling of ways.
“Vital” comes from the Latin root for life. From Ms. M to every patient I followed after her, I soon realized that clerkship year would be a year of unnerving vitality—conditions simultaneously taking on life while altering patients’ lives forever.
Learning how to grapple with this solemn reality on a daily basis was brightened by moments of hope. As I was leaving the hospital one afternoon at the end of my second week, I did a double take. The patient whose failing heart had barely squeezed on the screen was waiting by the exit, clutching his white paper bag filled with guideline-directed medical therapy—his lifeline. I almost didn’t recognize him, no longer in a hospital bed in a speckled gown but sitting upright in a chair in his jeans and a t-shirt. I smiled reflexively as his characteristic joyful grin spread across his face. “Bye, Mr. R!” I waved as I walked out the door into the sunshine.
Vitality had been restored. While this may not be the case for many of the patients whom we treat during our training and throughout our career, these brushes with vitality—both the ups and the downs—are what bring meaning to our work. They are what bring us back to the hospital every day. They remind us why we have chosen to practice medicine.
“I’m in good spirits today,” Ms. M told me the next morning. “Nothing’s going to hold me back. Even if I won’t have my feet, I’ll still have my family and my community. I’ll still have my life.”
Aidan Crowley is an MS2 at the Perelman School of Medicine.
Art by Catherine Yang, an MS2 at the Perelman School of Medicine.
