Yesterday, around noon, we admitted a man in his 50's with known severe heart disease. Apparently, he had been somewhat stable until a couple weeks ago, when he stopped with 4 heart medications. Why? Probably financial, given that even inexpensive medications require time and money to travel to the pharmacy to get refills. Also, many people only marginally believe in "western" medicine, and gravitate often to their traditional healers. And given our lack of ability to help in some situations, it can be easy to sympathize with their skepticism.
At any rate, here he was, sucking air even with our most aggressive form of giving him oxygen. His blood pressure was low and his heart rate was fast in an irregular rhythm called atrial fibrillation. We don't have much to do in this situation, except to restart his prior meds at a bit more aggressive level, paying special attention to try and not lower his blood pressure further. I sent him to our little ICU because (for once) they had room available, even though it had been decided that he wouldn't be intubated if his breathing should ultimately fail.
He died at 3am last night. Even though I was on call, I didn't find out until this morning, which was a bit surprising, but overall fine, since I wouldn't have done anything differently.
He was one of a hundred cases that haunt me. The memory of it will play around the edges of my mind, while I go about my work, laughing with the interns, building a block tower with Maggie, watching the birds, deciding on a course of action for the next patient. Just a bit of a whisper:
Could I have done more? Maybe if I had stayed at his bedside all night instead of in my own bed, I could have bought him some more time. Wouldn't that have been worth it? I should be working harder. Tenwek is all these people have for options. Maybe it would have helped. Maybe if I worked harder...
I think about it when a workday seems kind of light, and I get home at a good hour. I think about it when I discuss a new patient over the phone with an intern and decide that I don't need to walk up to the hospital to see the patient for myself. When one of my colleagues works harder and longer than I do.
Some of this is some kind of warped fear that I need to earn God's approval by trying harder. Some of it is knowing that I have been given much, and much is expected of me. 350 years ago, speaking of medicine, Thomas Sydenham wrote: "He must one day render to the supreme Judge an account of the lives of those sick men who have been entrusted to his care." I wonder what this means.
In the end, there is always more work to do, and we have to make decisions about our own limits. And truth be told, I'm pretty comfortable with where those limits have fallen for me. I'm pretty comfortable, but not one hundred percent. Our lives of full of a lot of great joy, and we thank our all-gifting God for it. Nevertheless, a small whisper continues to haunt. Maybe this discomfort is necessary to keep us diligent. I'll seek some conclusion, but it may just be one of the burdens intrinsic to what we do here.