“. . . for the secret of the care of the patient is in caring for the patient.”
With trembling hands, I held my identification badge to the electronic card reader. The motorized doors opened slowly, and my first day in the intensive care unit (ICU) officially began. It was only 4 am, but I knew that I needed all the time that I had to be fully prepared for rounds at 7 am. I walked from room to room, my senses filled with the sights, sounds, and smells that would dominate my life for the next 4 weeks. The musical alarms of the ventilators combined with the beeps of the cardiac monitors, infusion pumps, and other equipment were my first experience with the symphony of sound that all young doctors come to know during their training in the ICU. It was anything but quiet. At the end of the hallway, in the very last bed, was a young man whom I did not yet know but who would leave a lasting impression on my heart and soul.
Mr. L. had been born to a family of farmers near Monterrey, Mexico. At the age of 17, in search of opportunity, he had made his way to the United States, where he eventually joined his older sister in Houston. His efforts to find work were cut short when he began to experience shortness of breath, nausea, and anorexia. Finally, an enlarging inguinal mass prompted him to seek medical care at one of Houston's county hospitals. Biopsy results revealed testicular seminoma.
Despite several cycles of chemotherapy, no remission occurred and his disease progressed rapidly. By the time I met him in the ICU on that foggy February morning, cancer was invading his lungs, bone, liver, and brain. Large pleural effusions refractory to thoracentesis had led to respiratory failure and eventually his intubation. He would turn 19 years old in 3 weeks.
I had been assigned to present Mr. L.'s case during rounds that morning. Assuming that he was asleep, I quietly entered his room. The ventilator continued its slow, rhythmic oscillations. Outside his window, the darkness was interrupted only by a few faint streetlights. I approached his side and lifted my stethoscope off my neck. Suddenly, his eyes opened and met mine. In his eyes, I sensed many different emotions, but above all were profound loneliness and sadness. I completed my physical examination, sharing with him my findings and then offering him what I believed would be his medical plan for that day. From him, I saw nothing but confusion and frustration. I knew that I was only an intern on my first day in the unit, but could I really be that far off? Later that day, I learned that Mr. L. did not understand a single word of English. To beware of assumptions was the first of many lessons he would teach me that month.
As my rotation continued, my relationship with Mr. L. began to grow. His intubation and resultant inability to speak made communication between us difficult. For whatever reason, my repeated attempts to have him write down his concerns and requests were not successful. His sister visited him as often as she could, and she proved to be invaluable when it came to understanding what he was trying to tell me. Each day, I shared with Mr. L. some information about myself and news from the outside world, hoping that I might take his mind off his illness.
I learned that we shared a love for sports, and when time and circumstance permitted, we watched them together on the television in his room. Each night, I studied and carefully rehearsed the Spanish that I might need for the next day. My working knowledge of the language grew rapidly, driven by my deep desire to share more with my patient.
Mr. L. earnestly expressed his desire to be extubated. At my urging, and under the guidance of our critical-care fellow and attending physician, our team made several attempts to extubate him. In one instance, his ventilator values improved enough to make this possible, and he spent a few hours breathing on his own. Unfortunately, this happened while I was away from the unit, and I missed what would be my only chance to hear him speak. Before I returned, he and his sister had asked for the breathing tube to be reinserted.
My time in the ICU ended on a beautiful spring day, when the world outside the hospital was filled with life. That morning, I entered the unit with even more trepidation than that on my first day, because I knew how hard it would be to say goodbye to Mr. L. This was not simply because I would be moving to a new rotation at a different hospital, but because I knew my friend was dying and we would not see each other again. In the waning days of my rotation, he had begun to experience multiorgan failure, and his sister had asked us to do whatever we could to make him comfortable. Just before I left the hospital that evening, we shared our final moments together. His eyes revealed that he was at peace. His handshake was surprisingly strong. As I walked toward the doors of the unit, I was struck by how quiet the whole place now seemed to be. Two days later, Mr. L. passed away in his sleep.
For me, Mr. L.'s death was devastating. His was an incredibly sad story: a man not yet 20 years old, dying alone, far from his parents and his home. Months later, during tearful reflection on my time with Mr. L., it occurred to me that—despite the strength of our friendship and the deep impact his death had on me—we had never talked with each other. I would never hear the sound of his voice. Regardless, even without words, we had shared so much. He did not need to speak to be an excellent teacher.
From him, I learned that the best way to show compassion for the sick is not always to say the right things, but rather to do the right things. I have cared deeply for many patients, but none has left such an indelible mark on my medical training and experience as has Mr. L. Together in the ICU, a place so full of sound, we found meaning in silence.
Submissions for Peabody's Corner should 1) focus on the interpersonal aspects of a specific patient–doctor experience; 2) be written in storybook fashion; 3) contain no references; and 4) not exceed 5 double-spaced typescript pages.
From: Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, Texas 77030