Yesterday in Advanced Physical Diagnosis my classmate Blair and I met a man who was nearing end-stage liver disease. In the book The House of God, there is a patient with hepatitis who is named the Yellow Man, and the description fit well for this patient. My Yellow Man was a lanky gentleman with short messy brown-black hair, with a complexion that could be considered olive under normal circumstances, but was now a sickly yellow tint. All of the waste products from broken down red blood cells that couldn't be cleared through his diseased liver were built up in his blood to the point of making him yellow. Yellow Man said that he had been having nosebleeds for the past two months without relief. In interviewing him it became apparent that he had hepatitis C, a liver infection that eventually leads to scarring and liver failure. It was difficult to determine how he had gotten hepatitis, but he was under the impression it was from a blood transfusion. As his liver became more and more scarred and cirrhotic, it failed to produce the clotting factors needed to stop small bleeding, which resulted in the nosebleeds. The scarred liver also blocked bloodflow back to the heart, leading to distended esophageal varices (veins) as the blood sought to return by another route.
As we started our physical, one of the first things I got a closer look at was the Yellow Man's eyes. As I shined my penlight on them, the white of his eye was completely replaced with a sickly yellow tint. Feeling his abdomen, I could feel his massive liver moving with every breath.
I went to Ed and Beth Courtney's house for a church leaders appreciation dinner, and got to talk with my pastor John Drage. As I told him about the Yellow Man, he asked me how long he had to live. I couldn't say, but said that he is likely nearing the end-stage of disease, as he is losing all normal liver function. I told John he would probably die by bleeding out from a ruptured vein in his esophagus or bowels, or maybe he might succumb to a toxic death as his liver fails to process his body's waste, or maybe he'll die from multiple drug interactions, or something else. John asked me how hard it is to face the reality of working with dying people....
As I was climbing the steps of the parking garage this evening I noticed the hearse parked along the side drive, and then spotted the covered gurney being wheeled to the hearse. It is a scene that most people never see, but happens all the time. It isn't the first time I have ever seen a draped gurney wheeled from the hospital complex, but I've been thinking about mortality since seeing these latest two.
The medical examiner's office is in the same hallway as the anatomy lab in the medical school. It is actually a reasonable distance from the rest of the main hospital building, as though some distance can separate the healthy from the deceased (I'm not certain where the morgue is, but imagine it is likely in the basement, also out of sight). Many people have heard the stories of the false-bottom beds being used to transport dead patients out of sight of everyone else, in an attempt to hide death. Doing everything possible to remove a sense of death from the hospital, I imagine, attempts to convey a sense of health and life. Even in posters and brochures for hospice and end-of-life care the patients look vibrant and lively. Heaven forbid those who walk through the hospital doors never leave breathing.
I've also heard many times how hard it is when your first patient dies. It seems counter to what the doctor is fighting against with his entire existance, yet at some point everone dies. Perhaps it is more comforting for the patient to die outside the hospital, either at home or en route or anywhere else but here, in the house of health and healing. At least then I think I wouldn't have to play the what-if game of what I could have done differently, because I was not able to get to the patient. But once the patient is in the hospital and under my care, the failure to reverse the progression of disease lends to self-doubt. What we all need then is the courage to face the reality that everyone who enters the hospital, from those who work for health and those who seek it, will someday die, and it may just happen while they are trying not to.
