Perspective

During my internal medicine rotation, I took care of a gentleman with end-stage heart failure. He was young (early 50s) and personable, and I saw him every morning for a month. I followed him on a journey, we went through the ups and downs together, and I spent at least an hour in his room every day explaining his test results, answering his questions, and trying to help make the whole process less scary.

It was quite a roller coaster. The plan was for a heart transplant, up until one of his screening labs came back positive, and suddenly it looked like he might not get a heart after all. It took an agonizing week until the definitive follow-up test came back negative and he went on the transplant list after all. I got to know this man over the month that I took care of him, and it was gut-wrenching to watch him pace the halls, IV pole in tow, waiting to hear whether he would go on the transplant list or simply be allowed to die from his disease.

Once the decision was made to place him on the transplant list, he was going to receive a left-ventricular assist device – a pump that attaches into the heart muscle itself and helps the heart to circulate blood. Before a patient can receive this device, the workup is extensive. The device has a “drive cable” that exits the chest and attaches to a battery pack. The patient must be capable of caring for the device and keeping the drive cable clean. They must be able to remember to charge the batteries. On a more spiritual level, because the LVAD circulates blood through a continuous pump (instead of pulsatile contraction of a heart chamber), patients with an LVAD have no pulse. They must be counseled about this, and some patients react poorly, wanting the device removed or complaining that they feel “dead” when they can’t feel their heart pounding after going up a flight of stairs.

This gentleman passed the tests, and was scheduled for his LVAD placement on the last day of my rotation. My supervisors kindly let me out of my regular duties to attend his surgery, and the cardiac surgeon let me scrub in. It wasn’t my first time in the OR (far from it!) but after getting to know this patient, the usual OR routine seemed so harsh. Roll the patient onto the operating table, remove the gown, put the patient to sleep, insert the Foley catheter into the bladder, scrub the chest, place the drapes. Eventually, the anesthesiologist asks the PA who the patient is – what isn’t in the chart? The PA glances up for less than a second and says “Some drug addict getting an LVAD. They’re even putting him on the transplant list, can you believe that?”

I knew exactly what she was talking about. The positive test that had turned everything upside-down was for hepatitis C, usually acquired from IV drug use or high-risk sexual contact. When the test came back positive, he was shocked. The next day, he told me that he tried IV drugs once in his 20s, but he never got sick so he figured he was fine. He admitted to occasional marijuana until 6 months ago, and he had a positive drug test for cocaine a year ago. He denied cocaine use, and marijuana is often laced with cocaine, so I absolutely believe that he was unaware of the cocaine.

I understand where she was coming from when she called him a drug addict, but it shocked me hearing her put it so simply. I had gotten to know him as a friendly, middle-aged guy who asked a lot of good questions and didn’t want to die. To the PA, though, this was just another patient, another chart, another guy with a history of bad decisions who showed up on her doorstep wanting to be fixed.

As a fourth year student on trauma I saw a lot of patients who look similar on paper – drug and alcohol history, bad decisions, rolling through the hospital doors broken. I try to remember that it’s all in your perspective: if all I look for is what needs fixing, then that is all I will see.

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