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The Art of Medicine


Katers, Laura MS, MCHS, PA-C

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Journal of the American Academy of PAs: March 2015 - Volume 28 - Issue 3 - p 60
doi: 10.1097/01.JAA.0000460910.17355.75
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In medicine we make all kinds of assumptions in the first few seconds we interact with a patient. The energy exuded in these seconds can affect the rest of the visit, the day, and sometimes even the patient's health long term. Those seconds can't be done over, and I sometimes forget to wipe concern for the previous patient off my face before I greet the next. I had just such a concerned look on my face when I first met Andrew.

“Hey, doc, whoa! What, are you constipated?” he said, followed by a wry chuckle. Andrew had thin hair, cool skin, and an aluminum walker. He had diabetic neuropathy and chronic pain, and received methadone for heroin addiction. Andrew was entering his 63rd year. I was in my second day practicing in a community health clinic. On the surface we couldn't have been more opposite, but I recognized a familiar look in Andrew's eyes, the mischief resting there like a matchstick. Almost immediately, in the magical way that strangers connect—in a way that makes me entertain the possibility of past lives—we were kindred. Ignited by a shared humor and equal stubbornness, a relationship of respect emerged.

He was a fixture at the clinic, with medical records spanning 25 years and several providers. Over 8 months, Andrew quickly devolved through a series of medical ailments—a nonhealing foot ulcer, more chronic pain, insomnia—with little reprieve. I argued against giving him diazepam or zolpidem for sleep because of the methadone, the risk for respiratory distress and falling.

“I don't have much time left on this earth, doc,” he would plead, that matchstick in his eyes close to lighting. “What's the harm in giving an old man something to sleep? Something to take away the pain?”

He would frown, “I am the loneliest man.”

Then he would chuckle, say “Gotcha,” a spark in his eye. But I believed him, in his loneliness. I had an arsenal of meds before me. Why not give him what he wanted?

Late on a Thursday I rounded the corner at the clinic and saw Andrew in the procedure room. At first I didn't see his foot ulcer, or the nurse tending to it; what I saw was textbook heart failure. His skin was the color of old snow, with 30 lb of extra fluid resting against his bones. He was sipping the air.

After 3 L of oxygen, a blood draw, medication adjustments, and glimpses of his humor between tiny gasps of pain, he left with a list of alarm symptoms to watch for. But he was an alarm symptom, and we both knew he would never be hospitalized. People like Andrew never are.

I walked him to the door, concerned. “Take care, Andrew,” I said. He stopped, blocking traffic, and held me for a moment in his gaze. A moment as still as the moment between breaths. As still as the miniscule space between heart sounds. That moment was more than a stubborn man looking at a young provider. In that moment, I knew Andrew would die. I saw the blue veil of humor fall away to plain red suffering. He was finally letting me see, and I didn't look away. One second ... 2 seconds ... and he was gone.

A deputy called the office to ask, “What was the actual cause of death?” I could think of only five things: pulmonary embolism, aneurysm, cardiac dysrhythmia, structural deficit of the heart, trauma. But I didn't want to write any of those. I wanted to write about his laugh, and how he always laced his misery with humor. I wanted to mention his horrific childhood of abuse where he turned to alcohol and heroin to escape. I wanted a space for the day he arrived with broken glasses and we fashioned new ones, giggling, out of cotton swabs and athletic tape. I had no idea how he died. Was he alone in his last moments? What I ended up writing was, “Heart failure. No opiate abuse suspected.”

“It looks great, Laura,” the pleasant-sounding medical examiner said. “It's a beautiful death certificate.” It was my first one.

That night I went home and dug through pockets to find a crumpled note I'd scribbled in haste the last time I saw him in clinic. “Andrew,” it said. A reminder. I'd meant to call him every day, but I became lost in the next chart, and the next. What would I say? Would he answer?

At the funeral, his sister said she appreciated the way I described Andrew because it was how she remembered him, before the drug use, before all the pain.

“That's the Andrew I always knew was still there,” she told me.

That's the one I got to see.

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