Heart of a Doctor

#medstories #intraining

In the past few years, the AANP — America’s professional organization for nurse practitioners — has sadly capitalized on the slogan “Brain of a Doctor, Heart of a Nurse,” with other NP news outlets routinely implying or outright stating that an NP’s compassion for patients is unmatched by a physician’s. Informal social media campaigns have played into this new stereotype, wherein it is implied that a physician does not participate in patient-centered care. The implication that those who once served as nurses and later become NPs have a monopoly on “heart” is a grossly false representation and a frank disservice to our patients.

As a young physician who has completed years of clinical training, I single-mindedly became a physician in order to help people in their time of greatest need. My colleagues and I devote our twenties to advancing our medical education, often sacrificing the hours following a shift to further serve our patients. This practical education and the many hours we spend studying medicine outside the hospital contribute to our ability to minimize the risk of medical error and maximize the benefit our patients receive in their interactions with us as physicians. I personally invest in my patients, setting aside the emotional toll a death or unfortunate outcome takes on me so that I may approach my other patients with positivity and compassion.

“Heart of a Doctor” is the story of just one patient I had the privilege of caring for during the 72+ hour-long weeks I spent in the Medical Intensive Care Unit (MICU): Mr. Rahil Aslam—

“Mr. Aslam! You’ve got the same last name as the famous singer I see,” I smiled as I walked into the room. Mr. Aslam looked confused at first before shooting me a wide grin though the BiPAP (bilevel positive airway pressure) device that was keeping his oxygen levels up. He came to the MICU because he was at high risk of hypoxic respiratory failure.

“Ah yes yes,” he said through forced breaths, “Voice of gold.”

I sat down by his bedside before introducing myself, “I’m Dr. Pavitra, I’ll be the resident physician taking care of you here in the ICU. Tell me more about what brought you in.”

Mr. Aslam told me about his history of lung cancer, now metastatic to his spine, but possibly improving with a new line of chemotherapy his oncologists had recently placed him on. It was a last line therapy with a low chance of success, but Mr. Aslam was young and wanted to give this fight his best shot. He had, after all just been married to a beautiful young lady from his home country just a few years earlier, before they had discovered the cancer. Earlier in the week, he was having a bit of trouble breathing. His symptoms waxed and waned, but today they became constant and he just couldn’t move around like usual. Given his history of cancer, his family brought him straight in to get evaluated.

“He’s had multiple pneumonias in the past, I just wanted to make sure he gets through this,” his brother said through the phone, “His wife is his primary decision maker, but of course she discusses those decisions with the family. I’m not sure when she might be available to speak with you all.”

“Well, Mr. Aslam,” I told him after our first visit together, “it looks like you may have another bout of pneumonia, which is making it quite hard for you to breathe right now. The good news is that you’re holding steady with the BiPAP right now, so we will not have to think about putting you on a ventilator at this moment. I’ll check in on you throughout the day and tomorrow as well to see how you’re doing and we’ll adjust accordingly, does that sound good?”

“Sounds good,” Mr. Aslam sounded fatigued between breaths, “I don’t want to be placed on a ventilator though,” he managed to say.

“Okay. Let me see if I can update your wife as well.” I spent the rest of the day trying to get a hold of his wife. Meanwhile, Mr. Aslam’s breathing became more and more strained throughout the day. He remained insistent that we not intubated him and better control his breathing on a ventilator. Finally, his brother called, saying that Mrs. Aslam was aware of her husband’s condition and would be in the next day to discuss further.

I checked Mr. Aslam’s oxygen saturation that evening after 14 hours at the hospital before leaving — it teetered around 91–92% at the highest settings we could place Mr. Aslam on before intubation. “Please don’t crash,” I uttered a silent prayer before leaving the monitoring station to go home.

The next day continued to be rocky, with Mr. Aslam’s oxygenation threatening to drop dangerously low multiple times. It was in this setting that I finally met Mrs. Aslam, a petite young woman with her hair pulled back into a short ponytail and a scarf wrapped loosely around her neck. She sat by Mr. Aslam’s bedside, holding his hand and occasionally texting him. Mr. Aslam was too tired by now to talk and breathe at the same time. She knew she was tasked with convincing her husband to undergo intubation. She knew the BiPAP was simply not sustainable unless something drastically changed for the better.

Three days later, she was finally successful, with Mr. Aslam agreeing to an elective intubation with the caveat that we would keep him as awake as possible, so he could still interact with his surroundings and his wife. The way they smiled at each other brought a degree of sunshine into the room that one doesn’t expect to see in a closed intensive care unit during the winter months. Mr. Aslam was intubated without incident until one night, he nearly stopped breathing on the vent. At that point, he needed to be sedated emergently to protect his life. Mrs. Aslam found out the next day when I finally reached her and recounted the events that had transpired.

“So, he’s not awake anymore?” she asked. My heart broke, hearing her voice on the other end of the phone.

“No,” I said, “we’re helping him stay asleep with some medications because he wasn’t able to breathe while he was awake. If we remove the sedation at this time, I can’t guarantee he will be able to breathe well, but I want to make sure we’re talking about this because I remember he wished to stay awake as much as possible during his hospital visit.”

A long pause followed before Mrs. Aslam answered. “If he needs it in order to breathe well, then I don’t think we have an option. I just wish I had stayed a little bit longer yesterday while he was awake.” She came into the hospital every day, sitting by her husband’s side. First, she talked with him, then she spoke less. Over a week and a half into his hospitalization, she just sat by his side, holding his hand.

Meanwhile, it had become my practice to check Mr. Aslam’s oxygen saturations the second I walked into the ICU before even putting my things down and settling in at my desk, and right as I was about to leave. He had developed Acute Respiratory Distress Syndrome (ARDS), a condition that was not easily fixable. Out of all of my patients, he was the most ‘touch and go,’ and I sat by his bedside trying to figure out what else I could to in order to improve his ventilation. Every day, the ventilator settings required to improve his breathing increased. Every day, his breathing became a little worse. Every improvement in his chest X-ray was a small ray of hope that was quickly dashed by his condition the following day.

Discussing his condition with Mrs. Aslam became excruciating as I seldom had good news to give. We would sit in the family room, with Mrs. Aslam’s eyes downcast, every so often glancing up at me, begging me to give her some good news about the man who she had moved across the globe to be with. As I got to know her and her story more, I felt just a glimmer of Mrs. Aslam’s pain.

Mr. Aslam became the patient I thought constantly about at work, and checked constantly on over my EMR during my one day off a week. I knew everything there was to medically know about him and his condition — it consumed my every waking second and kept me up at night. He is the first patient my nurses saw me cry over and the gentleman for whom I once marched into my supervising physician’s office, refusing to leave without a good explanation as to why we weren’t choosing to prone or use adjuncts to clear his airway. Mr. Aslam had so little to lose.

Recognizing how personally invested I was in his care, the supervising physician looked at me and said, “I want you to know that medically, this may do very little for the patient, but the fact that you are here instead of finishing up your notes and thinking about how you may get out of here on time today, tells me you care deeply about at least trying it. We’ll give it our best shot.”

Nothing helped.

“If you’d like,” my supervising physician finally said, “I can have the end of life conversation with his family…”

I sighed, knowing we had done all we could do. “Let me,” I volunteered, “I owe it to Mrs. Aslam.” That conversation with Mrs. Aslam was the most painful I’ve ever had. We sat side by side on the stale brown couch in the family conference room and I started the conversation slowly until Mrs. Aslam interrupted.

“He’s not going to make it, is he?” she asked, her eyes welling up with tears. I stared directly at her question and finally shook my head, unable to say the single syllable in the English language that Mrs. Aslam least wished to hear at the time. I handed her a tissue, fighting back tears myself.

“I’m sorry,” I said.

“I understand. I know you’re a doctor, this is probably somewhat normal for you,” she said, “You’re probably used to it.”

“No,” I replied, “I don’t think I’ll ever be used to it.”

Mrs. Aslam looked up and noticed the lone tear that had adamantly fought its way out of my left eye. She handed me a tissue.

“He has been an amazing husband, you know?” she said, “When I first came to this country, he wanted to make sure I could take care of myself. He helped me go to community college here, taught me how to drive, told me how important it was for me to be able to get around this new society. The last thing he said to me was that he loved me and wanted me to be happy. I wish I had a chance to say goodbye,” she cried.

I sat by her side, holding her hand.

“Want to see some pictures?” she asked. I nodded yes before she opened up an album on her phone and scrolled through, reminiscing about the first apartment they had together, their first car, the house they had just bought months ago in order to make space for the new child they were planning on having once this round of chemo concluded for Mr. Aslam. “Rahil was my life,” she said, “Many husbands, they aren’t as good, but I got so lucky. If even to have him for a few years of my life, I got so lucky to have such an amazing, kind, and caring man for a husband. We were really in love, we were really happy,” she choked up.

I put on a smile and saw my other patients that day. And before I left, I checked on Mr. Aslam’s oxygen saturation as I usually did and sat by his side, uttering the prayer of gratitude under my breath that I did for all my patients when I was no longer sure I would see them the next day:

“Thank you,” I said, “for giving me a chance to get to know you and the honor of taking care of you over the past almost month now, Mr. Aslam. I saw your wife today too, I think I may have dashed her hopes, but I promise I sat by her side and held her hand until she was all out of tears. This is not the ending I foresaw for us, but I want you to know that I cared for you the best that I possibly could. And, if this is the last time we have a chance to speak, I want you to know that your family and your care team — we’ve all witnessed the ferocious fight you’ve put up this month as well. Thank you.”

I left that day, still checking all of Mr. Aslam’s labs through the evening. I checked his notes, his progress, secretly hoping that the universe would prove me and every medical professional wrong by saving Mr. Aslam’s life. I lost my appetite for dinner and ate a small breakfast the next morning before heading to a massage I had booked for my one day off. He was alive before I walked into my massage and by that evening, his soul had moved on. I sat on my couch for what felt like an eternity, staring at his medical chart and imagining what the process of withdrawing care must have felt like for his family and for Mrs. Aslam.

The next day, his room was empty — clean white sheets draped the bed, beckoning for another patient to occupy what had become “Mr. Aslam’s room” in my mind. Shortly thereafter, Ms. Vega was admitted to that room. I took a deep breath, reminding myself that Ms. Vega didn’t know of the previous occupant of her room or his untimely demise.

Putting on a smile, I walked in, “Ms. Vega!” I exclaimed, “I’m Dr. Pavitra, I’ll be the resident physician taking care of you here in the ICU. Tell me more about what brought you in.”

Pavitra P. Krishnamani is an EM resident physician with a background in global health interested in innovating how we deliver healthcare to our patients at home and abroad. To learn more about her and her work, check out her website.

*Publish dates for articles discussing patient encounters are disparate from when the encounter actually occurred in order to protect patient privacy. Names, ages, and other encounter details are also modified to protect patient privacy.