Something Missing

Ashlin Mountjoy, MS4 at UCSD SOM, PRIME-Health Equity

There’s something missing.


It seems like a pretty comprehensive list. At least it’s a familiar list – the way the ICU attendings want us to present the information.

Neuro: she is minimally responsive.
CV: Her heart is stable.
Resp: Her breathing is apneic and agonal. But it’s more comfortable today than yesterday. Will start a morphine drip.
FEN/GI: She’s not eating much anymore. Do we need a feeding tube?
GU: Minimal urine output. Foley in place for urinary retention. Check.

Multiple calls placed to SNFs around the county. Can’t find a bed there, will check with another. Is the son ok with this plan? Is the monthly cost ok? Can she go to a SNF? Plan to discharge today.

Currently stable.

There’s something missing.

Does anyone put the pieces together? Where in the progress note is the big picture? The whole person? The person with multiple organ systems failing.

pssst…she’s dying. She’s not stable. She’s dying. She’s 102 years old. She’s comfortably dying. Dare I say she’s appropriately dying? We can let her die in peace.

No morphine drip. No feeding tube. No foley.

Something’s missing.

Something’s missing.

Can I fill in the gap?

I wrote this while on a Palliative Medicine rotation. I was struck reading through charts of my dying patients how little attention the broader medical field gave to the ultimate direction our patients were headed, how rarely the word death was mentioned. Sometimes we need to take a step back and look at the whole picture and accept it.

Lost Cause?


“What’s he doing here?” the attending asked the nurse before entering the exam room.

“STI testing?” the nurse replied, shrugging her shoulders.

It was interesting to have a teenage male scheduled at the Women’s Clinic, but it wasn’t an infrequent occurrence given the proximity of the clinic to a high school. Most of these young men would present for concerns about sexually transmitted infections or for a bag of free condoms.

“Keep working on your note, I’ll take care of this one,” she instructed as she opened the door and greeted the young man. I worked quickly, trying to finish my note before she exited the room.

To my surprise, the door opened after 5 minutes and my attending trudged out of the room shaking her head. I could tell she was distraught as she fell into her chair and let out a sigh. It was none of my business. Silently, I continued typing.

“What a waste!” my attending exclaimed, catching me off-guard. “Can you believe these kids?!”

“What’s wrong?” I asked, curious to know what transpired behind the door.

“He’s coming in because one of his partners told him she has chlamydia. When I asked about recent sexual contacts, he said he had been active with about 10 girls and doesn’t know how to contact them,” she recounted.

“Are you testing and treating him?”

“Of course,” she replied, annoyed at the question.

“What did you tell him?” I asked out of curiosity.

“Nothing, he’s a lost cause… He refuses to wear condoms and doesn’t want to tell the girls he was with about his symptoms. I give up!” she said throwing her hands in the air.

“But, what about the girls that sleep with him? He is putting others at risk with his risky behavior,” I commented.

“Any girl willing to sleep with him, deserves….” she started and fell silent as the patient exited the clinic. With that, the conversation ended. There was nothing more to say.

I can understand my attending’s frustration, having counseled many teenagers about STIs without much impact. But, is that reason enough not to try? Even the smallest impact may be beneficial.

Having experienced a sexually transmitted infection, this young man may have been more open to learning about how to prevent future infections and other consequences of his sexual practices. Furthermore, we have a responsibility to the community to educate young men like this one to prevent the transmission of infections.

Just because we think that we will fail in changing the unhealthy behaviors of others, doesn’t mean we shouldn’t try. An action as simple as introducing an idea may pave the way for future change.