When We Dream of Patients

Gilbert Williams
Visionary art by Gilbert Williams, https://www.facebook.com/gilbertwilliamsgallery/

By Shanon Astley, MS4

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

I met Mr. M after his second code blue. My team was on-call and surgery had been consulted. He was obtunded, intubated and bleeding internally following a myocardial biopsy. He was also young. His 5 o’clock shadow overlay jaundiced skin and his abdomen swelled with his and transfused stranger’s blood. Medical staff surrounded him, keeping him alive with tubes and lines while chatter of how to save him filled the room.

He would code a third time before coming to the OR. I stood at his table, scrubbed in, with suction in hand. By then, his face and limbs had been covered and all that was exposed was his hard and swollen abdomen – made orange by the PU surgical film. The incision was made and eight liters of blood erupted. As a medical student your overwhelming hope is that you are never in the way, and your best hope is that you are useful. I found middle ground between the two by scooping warm blood clots out of the field.

He had a liver laceration, which by no small feat, the surgeons were able to repair. With his liver and bowels abused too much in one day, it was decided he would be packed and closed later that week. The OR cleared out, Mr.M went to the ICU and with that, the pulsing electricity in the room fizzled out and time slowed. My resident asked for help spotting the blood splatters that the surgical gowns failed to protect against. Then I left to join the second case my team was on, and the day continued like any other.

It was hovering close 8pm, when we went to check on all our post-op patients. In a dimmed ICU room, a trauma-surg attending evaluated Mr.M. His pupils were fixed, dilated and devoid of pupillary reflex. A tap of a glove finger showed his missing corneal reflex. I listened to the attending and resident discuss the significance of these findings while my thumb nervously flicked back and forth over his right index finger. He felt cool to the touch, despite being buried under blankets.

That night I had a dream about him. Not how I had known him, jaundiced and unconscious with a belly full of blood – but in the way I wish I had. Moving around his hospital room laughing – he was having a conversation I couldn’t hear, with a family I never met. He gestured wildly as if telling a story, his face bright with life. I had overheard he had an ex-wife and daughter somewhere in the hospital, maybe that is who was in the room with him. Would they ever see him like this again?

I woke unsettled, thinking about Mr.M and what would happen. I carried those questions with me on rounds. When we arrived at his bedside, my resident told me his brainstem functions were present today – it was likely the anesthesia limiting his response. There’s not really a word for how I felt – relief, but something else. It was like standing at the door of a plane about to sky-dive with no parachute and then finding out you didn’t have to.  Nothing prepares you for when you almost lose a patient – and for the feelings that build up but then become inappropriate to let out. What do you do with them?

I struggled with those emotions. This was the best possible outcome, but still I couldn’t shake the weight of the moment. I felt its heaviness like a second set of scrubs – with me in every surgery and patient interaction, pressing down just enough to remind me it was still there.

Later in the week he returned to the OR and my team closed his abdomen. We signed off on his care shortly after. A few days later when we were no longer following him, I learned that as they weaned his sedative his extremities moved in response to pain stimulation. This would be the beginning of a very long journey of recovery for him, but it seemed like he was moving in the right direction.

Even though Mr.M was no longer in our care, I couldn’t stop my thoughts from returning to the dream I had. I don’t know the person he is when he is awake. I don’t know who his ex-wife and daughter are. And I don’t know what it is like to lose a patient. I do know that when I thought I had, my mind yearned for the opportunity to know the kind of person Mr.M was.

I can’t say how many times I had let my mind wander while retracting during surgery, or how many patient interactions I may have cut short so I could make sure to finish my notes. I don’t know if I missed out on opportunities to learn who my patients are as people. What I did learn from my patient, despite us never speaking, was a reminder of something I came into medical school innately knowing, but somehow lost during my third year rotations. The art of medicine isn’t puzzling through chief complaints, or knowing the most current guidelines or first line treatments. It’s in the small moments, when you learn your patient has a dog, or is a high school history teacher who traveled the world, or loves murder mystery novels, or has had trauma you can’t begin to imagine. It’s in sharing peer-reviewed publications with them because you know they have an inquisitive mind, in grabbing their hand and squeezing it to let them know you’re there, and in respecting how vulnerable they are.

When I dreamed of my patient, it wasn’t about the medical interventions necessary to save him – it was to understand who he was before his illness defined him.


Shanon Astley is a fourth year medical student at UC San Diego School of Medicine. She is one of 19 students nominated by her peers to the Gold Humanism Honor Society’s class of 2019.