Two Men - Zahra M. Malik
Mr. Warren
-Laura White
Parents aren't supposed to have favorites among their children and teachers aren't supposed to have favorites among their students — I wonder if it's alright for doctors to have favorites among their patients. I've had favorites. Mr. Warren was one of them.
He was just so easy to like — maybe it was that sparkle in his eyes.
I remember the first time I met him. Entering his room, I was surprised by his appearance — the crown of wispy curls framing a softly rounded face made me question whether I'd entered a female patient's room by mistake.
"Mr. Warren?"
"Yes?"
I had the right room.
"My name is Laura White. I'm a medical student working with the doctors on your team. I'll be helping to take care of you while you're here. Is it okay if I ask you a few questions?"
"That'd be just fine," he obliged.
So I asked my "few questions," and he told me about the insidious onset of his pulmonary fibrosis — a disease which had him on oxygen and long-term steroids with no potential for cure in sight. He told me about multiple hospital admissions for "tune-ups" when it became more difficult to breathe. He told me about the three months he had spent at a local nursing home since his last admission — he'd had to go because he was too weak to take care of himself at home. He had expected to get physical therapy, but the therapists had worked with him barely a handful of times. So he'd continued getting weaker, and one time he was stranded on a toilet for almost two hours unable to move himself and forgotten by busy staff members. He told me how his breathing had been getting worse again, requiring higher and higher levels of oxygen, so he'd come back.
"This time," he told me, "I don't want to back to Whispering Pines. I didn't get any better there. What I really want is to get back home so I can work in my garden and do my own cooking. Mmm ... There's this steak dinner I make ... I bet you'd like it." He grinned, and I saw that sparkle in his brown eyes for the first time.
I found myself beaming back. "Well, we're going to do our best to get you back home doing that cooking."
"I'll do whatever I need to do. I want to get on the right track. Just a few months ago, I was still living at home taking care of myself. I know I can get back there."
His determination, his optimism — they were beautiful, they were contagious. I felt it. I think each of his doctors, his nurses, his respiratory therapist, and even the unit social worker felt it. We were going to do this.
Tuning up his breathing seemed like it would be the simple thing — his doctors had been able to do that every time he came in. This weakness was the new and troubling issue, the factor that had kept him from going home. Why hadn't his nursing home provided the physical therapy which seemed so essential? If he could get it, would that make the difference? We could get him physical therapy while he was here, but I was concerned about what would happen after he was discharged.
I went to talk to the unit social worker. "You know Mr. Warren in 51? Is there a way we can make sure he gets physical therapy when he's discharged this time? They didn't really provide much at Whispering Pines."
"It's his insurance," she told me. "It won't cover both the nursing home cost and the physical therapy. I know that seems crazy. We could get him physical therapy at home, but he's too weak to go home by himself. Our best option might be to see if he can get approved for inpatient rehab. He'd have to be able to do some pretty intense physical therapy, but they might take him if they think he'd put in the effort."
"Oh, he'd definitely put in the effort. He's really motivated."
This seemed like a good option. I knew Mr. Warren would work hard — he really wanted to get stronger. Of course, the rehab specialists would see that. So we consulted them, and I watched his chart for their note.
"Too weak to be a candidate for inpatient rehab." The blunt words were scrawled across the evaluation section of their note. I felt indignant. Didn't they realize that this was his best chance?
I went back to the social worker. "I guess they're not going to take him."
"Yeah, I saw that.I talked with the unit physical therapists about it. They've got a plan. They're going to try to work with him as much as possible during the next few days. They're only supposed to work with him three to five times a week, but they're going to come a couple times a day if they can. Hopefully, if he can improve some, we can get the rehab specialists to come back and re-evaluate him."
I brightened. "Sounds like a great plan. That's really nice of them."
"They know him from when he's been here before. Everyone really likes him a lot."
So I watched the chart for their notes of his progress, but instead of reading about improvement in his strength and function, I saw comments like "too weak for therapy today," "unable to participate," "will return this afternoon," "will return tomorrow."
How had he gotten so weak? Perhaps it was more than could be attributed to disuse during an illness.
Daily, I would sit by Mr. Warren's bed and tell him the new things we were trying. "We're worried that there could be a neurologic cause for your weakness, so we're consulting neurology." "The neurologists think that your gout medications might be affecting your weakness, so we're consulting rheumatology." "The neurologists would like to do a study of your nerves." "The rheumatologists have suggested a way to reduce your colchicine." "The neurologists would like to get a muscle biopsy."
To each new plan, he responded with optimism. "It seems like we might be on the right track," he'd say. His eyes would sparkle, and he would tell me about something he was planning to do when he got "back on his feet" — planting a new breed of tomato plant, trying a new recipe for potato salad, visiting his mom in her nursing home, moving closer to his sisters in Washington, D.C. His hope inspired me — we would make this happen for him.
But his hope couldn't keep his oxygen saturations from dropping, and he went from using a nasal cannula to using a face mask to using a machine that provided continuous positive airway pressure. He wasn't excited about this latest development, but it helped him sleep through the night. He even looked more alert the next morning, but the sparkle wasn't quite as bright and we had no more talk of gardening or steak dinners.
We waited for the results of the tests, we waited for the notes from our consultants to give us new insight, we waited for the removal of old drugs and the addition of new ones to help. But the answers didn't come, and his blood pressure began to drop.
We had consulted the ICU resident a day ago when his oxygen requirement kept rising; we had wanted them to know about him just in case. Now, we had to call them for real. I wrote the transfer note, a five-page retelling of his condition and care on our service. I knew my resident would write one, too, but I knew him so well — maybe better than anyone else. My note would count for something this time; it wouldn't be the typically redundant med student note.
One of my classmates would be following Mr. Warren in the ICU. "He's really special, Matt. I wish you could have met him a week ago. Will you let me know how he's doing?" He said he would.
I couldn't just wait for Matt to page me. The next morning, I added another stop to my morning rounds and checked on Mr. Warren in the ICU. He couldn't talk at all any more. He had a tube down his throat and a machine breathing for him. His body was swollen as the fluid in his blood vessels leaked out into his tissues, and IV lines criss-crossed his body as the ICU team used multiple drugs trying to keep those fluids in and his blood pressure up. His wispy curls were now matted down, and his eyelids were leaden with sedation. He didn't look like the Mr. Warren I had known.
But I remembered the real him, the man who couldn't wait to get home to his tomato plants. I lingered by his bed and told him we were still trying to get him back there.
He didn't have any other visitors. It could have seemed strange that a man like Mr. Warren wouldn't have friends and family clustered around him, but I knew why. He hadn't wanted to worry his family, especially his mother who was ill herself in a nursing home. Yesterday when he'd known he was going to the ICU, he'd finally agreed to let us call his neighbor who was also his power of attorney, but we hadn't been able to reach him. I'd left multiple messages, and I would just have to keep trying.
The next morning, the eleventh morning since I had met Mr. Warren, I entered the ICU and walked to the chart rack to pick up his chart. It wasn't there. Maybe one of his doctors was still using it, maybe someone hadn't put it away properly . . .
A thin, dark-skinned physician whom I had never met glanced up at me through his wire-rimmed glasses. "Are you looking for Mr. Warren?"
I nodded.
"We withdrew care last night. We finally got in touch with his neighbor, and he came in and signed the consent." He turned back to the progress note he had been writing.
A strange numbness engulfed me. Leaving the ICU, I trudged up the five flights of stairs to the floor where I would start rounding on my living patients. I didn't know how to respond to this news, so I didn't respond. I just went through the motions of printing out rounds reports and looking up vital signs as I would have done any other morning.
Then I remembered Crista. She was my resident, and she would be stopping by to see Mr. Warren on her rounds this morning, too. This thought pierced through my fog: she needed to know. She should hear it from me — from someone who cared about him. Not the way that I found out.
I paged her. When she called me back, I told her what I'd learned
"Are you okay? Do you need to talk?" she asked.
"I'm fine," I said. It was Mr. Warren who wasn't fine, not me. "I just thought you should know. I'm going to finish rounding."
Coming out of Mrs. Simpson's room ten minutes later, I saw Crista. There was a hand on my shoulder and a repeated, "Are you okay?"
I started to answer, to say, "I'm fine." But my voice caught. Then she hugged me, and I cried.
Why did I cry? My life would not be any different. I had not known Mr. Warren very long at all — I had not lost much. But he had. He had lost hope and sparkle and determination and any chance of feeling the warm sun on his face or dirt between his fingers, and so I cried because something deep within me screamed that this loss had to be mourned. He deserved to be mourned. The coolly detached doctor in the ICU hadn't known that, but I did. So I mourned his loss — his losses.
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