It was February and very cold outside. I wiggled my toes in my new work shoes standing in the halls of HUP. This was my first week ever on an inpatient team, the very beginning of my clerkship year, and I had spent a long time picking shoes for this moment: comfortable but also sleek, so that I could be taken seriously by my team. As the discussion of rounds got more and more detailed, and slight fatigue began to creep into my legs, I thought about Tadasana, mountain pose in yoga. I drew on my background as a yoga instructor and energized myself to stand straight up.
Suddenly, everyone’s pagers went off and they started running down the hall, yelling something about someone on our list and a “rapid.” As the only medical student on the team, with no clear direction, I followed suit and ran behind.
We ended up in an MRI imaging suite. A woman I had never seen before was sitting upright on the scanner table at the center of attention, people buzzing all around her. There was a lot of yelling. “EKG is clear,” one person said. Though she was sitting there wide awake, no one was talking to the patient. They were very busy talking to one another. She was on some sort of breathing machine (which I would later learn was a nebulizer treatment), her gown had fallen to her stomach, her breasts were exposed to a room of about 20 people, and her eyes were darting around. She was breathing very fast. She was clearly scared. I thought back to yoga class, and I walked up to her. I lifted her gown to cover her breasts and I started to rub her shoulder and told her everything was going to be okay. I told her I was going to breathe with her, and I did. I stayed by her side and took deep breaths.
No one moved me out of the way—maybe it was because of my snazzy shoes?—but I ended up staying there until the end of that nebulizer treatment and then throughout another one. I held her hand while they eventually wheeled her back to the floor from the MRI suite. None of this felt out of the ordinary to me. It seemed like the natural human thing to do for another human. It was only until I left the patient’s room that the team leader of the rapid response approached me and asked who I was. Upon learning I was a second year medical student, he praised my “instinct” for “staying attentive to the patient’s socioemotional state” and that “it was key bringing down her respiratory rate, perhaps more so than any organic cause in this case.” He warned me not to lose that. I was confused.
Fast forward to about nine months later. I was on my very last clerkship for the year, Surgery. I had intentionally ranked the vascular surgery service first because throughout the year I had connected the most with this patient population—“vasculopaths,” as medicine calls them—due to the often vastly complex social and environmental factors interacting with their medical ones. One patient, Ms. M, was a perfect example of this. She had right heart failure, end stage kidney disease and a series of other medical concerns, but was in our care for surgical reversal of an infected AV fistula. I remember when she came down to the OR there were about once again 15 people in the room; she was too sick to undergo general anesthesia, and so a specialized team was there to do a local block.
When we moved her from the transport bed to the OR table, a few breath mints fell out from her hospital gown. Laughter erupted. One of the junior residents was enraged: “She’s supposed to be NPO, someone call up to the SICU. This should be safety netted.”
The vascular surgery fellow was amused: “Where’d you get these mints Ms. M?” As a response she meekly mumbled that she liked to eat mints. I kept my hand on Ms. M’s shoulder throughout the exchange but otherwise stayed quiet.
A few days later, it was clear Ms. M was not getting better. She had developed an ischemic bowel. The primary team was trying to facilitate discussions with the family to transfer her care to the palliative team, which was proving difficult, but we on the vascular surgery team weren’t privy to these discussions. As it stood, Ms. M was stuck in the SICU for the time being.
In the workroom, my fellow sat back in her chair and pondered a bit. She pulled a five-dollar bill out of her bag and told me to go down to the cafeteria and buy some breath mints for Ms. M. When I got to the SICU floor, instead of walking straight up to Ms. M—as I had to the woman I had never met, in the middle of a rapid response, months before—I felt the need to pause. I was cautious now of the medical aspect, because now I knew more. I was cautious of the fact that she was NPO. Of the fact she had a dying bowel.
And so I found her nurse and asked, “May she have these mints?”
The response came back, “No, she’s NPO.”
Ms. M died the next day.
I often think I had the power to give her some joy, in those final moments, and I didn’t. “The nurse stopped me,” I had told my fellow, but in reality, I stopped myself. In that moment of weighing the aspects of her biomedical situation, I overlooked her humanity. At the same time, I didn’t realize Ms. M had hours left to live. No one on the team had ever explicitly said that, discussed her prognosis. I wonder if I would have been more emboldened to act if I did. If she had made the transfer to palliative care and off the intensive care floor, this would not have been such a dilemma; she may have been met in her final moments with more compassion. But when I compare how brazen I was in my first month at HUP with my actions just nine months later, it is a bit shocking. Is this indeed what the mainstream culture of medicine does to us? As the rapid response attending warned me? Do we explore the intellectual exercise of theoretical probabilities of differential diagnoses at the cost of seeing a patient’s humanity?
Or in that moment was I just tired, after a long year as a learner? A long year of trying to maintain my view of humanism while simultaneously dehumanizing the body in the pursuit of understanding its pathology? Might it indeed be possible to treat patients’ disease while holistically attending to their humanity? These are the questions I ask when I see the mints still sitting on my closet shelf today.
Joia Brosco is a MS4 at the Perelman School of Medicine, the Co-President of Gold Humanism Honor Society and an Ashtanga yoga teacher.
