Not Another Cirrhotic

by Evaline Cheng, MS4.

As with all writing published on Stories in Medicine, locations and names in this piece have been changed.

“It’s not what you look at that matters, but what you see.” – Henry David Thoreau

Statue
Statue of man. Source: Addiction Hope

I stood frozen, staring at the man on the hospital bed. This was my first night on call during my medicine rotation at the VA, and I was in the emergency department to evaluate and admit a new patient. “Another cirrhotic,” I was told. On my way down, I carefully recited the stigmata of cirrhosis in my head: jaundice, ascites, asterixis, among other physical manifestations. We had learned about cirrhosis in our pre-clinical years, and I knew what those words meant. Yet none of that had fully prepared me for this encounter.  

His face was yellow and gaunt, both temples and eyes sunken in. “Mr. V,” I said as I snapped back from my initial shock. He grunted.  

“Mr. V,” I called out again, louder. His eyes rolled back into his head as he mumbled in reply. Did he even know where he was?  

His feet hung off the bed. His limbs were cachectic while his belly protruded as if he were hiding a basketball under his jacket. I introduced myself and explained what was happening. As I attempted to take a history, he occasionally answered with bursts of phrases before his gaze and attention trailed away. In the physical exam, I held his arms up and watched as his hands rhythmically jerked back and forth. He seemed to have decompensated cirrhosis with signs of hepatic encephalopathy, which indicated severe liver failure.  

From the pieces of my history and his chart, Mr. V was a 31-year-old veteran with alcoholic cirrhosis, surprisingly young for his state. He also had a history of drug abuse and had been taking methadone daily. I was not surprised to learn that he had been in the emergency department before. As a former EMT, I realized that the emergency department had an unfortunate reputation as a revolving door for patients who lacked resources. The alcoholics, cirrhotics, and drug users were expected tenants among those rooms. Yet when I left the hospital that night, I could not shake the image of Mr. V lying on the hospital bed, his body visibly deranged with disease. How did someone so young end up with severe cirrhosis? I was frustrated that he had continued to return to the hospital in the same, declining state. What else would this admission accomplish? There was no cure for his cirrhosis, and he was not eligible for a liver transplant. He would be labeled as “another cirrhotic.”  

Over the next days, I watched as Mr. V responded to our treatments and slowly improved. We removed 6 liters of bright, yellow fluid from his abdomen with a paracentesis. By day two, he was conversing clearly and asking me for more string cheese. His anxiety, tremors, and sweating from opioid withdrawal began to subside after I tracked down his methadone clinic and confirmed his dose. He even liked the taste of lactulose, which was helping to clear his hepatic encephalopathy. While I was optimistic about his improvement, I was reminded that this was the same cycle as his prior admissions for cirrhosis.  

By next week, Mr. V was nearly recovered and it was almost time for his discharge. When I bumped into him in the hallway, he stood taller now, one hand carrying the bag of urine draining from his catheter. He seemed cheerful as he said, “I’m going out to the rec deck for a smoke.” “Would you mind if I joined you?” I asked.  

We sat face-to-face on the outdoor patio as I reviewed his progress and updated Mr. V on the plan for upcoming discharge. Then, I paused, wondering if my next question would be too personal. “May I ask… how did you get to this point?” To my surprise, Mr. V began: He had graduated early from high school and enlisted in the Marines, where his drinking began and escalated. After multiple deployments, he relied on alcohol and drugs to self-medicate for PTSD, and his addiction continued into civilian life. He was divorced with 2 young sons, including a 9-year old with autism. He was a Christian, and he had started going to methadone clinic daily. I marveled at his insight as he said, “I know that I don’t have long to live. I regret my choices, and my biggest regret is knowing that my sons won’t have a father.”  

I held back tears as I walked away. Mr. V had been the stereotype of “another cirrhotic” with his cycle of admissions and substance use. Yet, I did not consider how his personal struggles had led to this point— that trauma from his service and years of inner turmoil cumulated in his condition. Could there have been more opportunities to intervene before he deteriorated? I was frustrated that his decline had not been prevented. At the same time, I cried for the loss that his sons would experience and for the magnitude of his regret.  

In asking Mr. V about himself, I was trying to reconcile my shock at seeing a young man, not much older than I was, with severe disease. In the process, I learned that he was motivated by his role as a father. We laughed at stories he shared about his boys, even though he did not see them often anymore. For his family’s sake, Mr. V wanted his end-of-life to be peaceful, and later that day, I helped him start an advanced directive to clarify those wishes. By setting my judgements aside and listening to Mr. V’s story, I began to see him as another human being instead of “another cirrhotic.”  

On his day of discharge, I saw Mr. V in the hallway again, his thin frame towering over a walker. He saw me and smiled, “I guess I’m out of here now.” I complimented his tie, mismatched and slightly too long. This was not his first hospital admission, and the odds were that it would not be his last. But as I watched him push the walker along, I hoped that he would make it.

 

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Evaline Cheng is a fourth year medical student at UC San Diego School of Medicine. She is one of the two winners of the 2018 Gold Humanism Honor Society essay contest. 

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