Thursday, May 8, 2014


This post has little or nothing to do with diabetes. It has to do with me at work, outside my usual wheelhouse. Oh, and I happen to have diabetes.

I gazed at the withering man, taking in the clinical information I needed through my eyes alone. His drawn skin, stretching over hollowing cheeks. His unfocused gaze. His well defined muscles gave away his substantial strength, but his arms themselves, much too long, gave away that those same muscles were far weaker than they had been up until this point in his life. I leaned over the hospital bed and placed my stethoscope gingerly on his chest. I closed my eyes to isolate my hearing, as I often do, listening for the sounds his still-strong heart was producing. I heard the familiar sounds of a cardiac monitor beep-beep-beeping in that muffled way they assume when the earpieces seal well in your ears.

But that cardiac monitor was sorely out of place. I opened my eyes suddenly, to verify that I was, in fact, not in a hospital, but in my patient's home. I hadn't heard the rhythmic sounds before, the sounds made by the rumbling clothes dryer as it clink-clink-clinked a button against the dryer wall, and I caught myself being too clinical when I needed to be less. I had to ease the suffering of a dying man and his reeling family, each in various stages of acceptance, denial, and coping with great change. I quickly wrapped up my exam, checking for swelling and for pressure ulcers, and I shifted my focus.

As I sat by his bedside and he told me stories of his childhood, his sister came over to hear. "I need to get the details of this story straight," she said. "I've always relied on him to tell these stories, but I have to learn them quickly now so I can carry them on."

I looked around as I listened. The hospital bed was set up in the side of the living room, by the large window. A cathedral ceiling rose over his head and drew his gaze most of the time I was there. His sister's cigarettes and lighter lay gently on the armrest of the couch across the room. His wife wrung her hands slowly and discretely as she hovered, lovingly, not knowing how to help or what to do for this man beyond her ability or mine to fix, only to comfort. A young girl--four? five?--giggled from the other hallway, chattered and giggled and giggled some more, before I realized there were two girls making those noises. This brought a thin but definite smile to his lips, each time the sweet sounds of his giggling granddaughters bubbled down the hall.

He was very weak today. His wife told me it was because he had insisted on a walk across the street yesterday, to see the creek. While they were out, struggling to help him walk, a storm came quickly, and they got caught in the rain as they walked him back to the house. He slowed down, lingering outside. He always loved the feeling of the rain coming down on his skin, they told me. He smiled at that too, but with melancholy this time.

His wife and I excused ourselves to the kitchen, where we talked about his medications--which ones he'd no longer need, which ones would make him more comfortable, and when and how much to give. She was very worried about the medications, but I assured her that there was really nothing she could do to hurt him. I explained that our sole focus at this time should be on easing any discomfort to the best of our abilities. We wouldn't be able to prevent all pain or confusion, but we'd minimize them as best we could.

I went back to sit with him once more, to hear another story of his ancestors, and to glean all I could from my rare visit to a patient's home.

The circumstances that led me there, rather than him to my office, were quite unique. It was the first home visit I had made in 10 years. The very first on my own. The others (all four of them) had been in medical school and residency.

The patient was grateful (not why I did it), as was his family (not why I did it). I did it because it was what he needed at that time. But it was transforming for me. More than almost anything else I do, it came with the knowledge that I truly and fundamentally changed the experience of his dying and was able to bring comfort in ways not so accessible in the office or in the hospital. I didn't follow any clinical practice guidelines. I didn't use any checklists. I didn't have an electronic medical record. I just had my stethoscope and a pen, and I didn't really need them, either.

I have to make this happen more often.

On my way in, his sister had shut a laptop that was open on a bedstand near his head. As I walked toward the door on my way out, she opened it again, and gospel music began to play, following me through the door, to my car, and lingering in my ears, slowly fading as I drove away along the creek across the street.

I take comfort in knowing that the gospel music was still playing there when he took his last breath this morning.

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