Originally published in JAMA, Feb 10, 1999
Dan's fears were confirmed. Despite three months of daily anxiety, the bottom line again read, "Pass." Dan's hands clutched yet another lukewarm evaluation to add to his ever-growing pile.
"According to your evaluations, you need to speak up more, Dan."
Dan glanced up at the attending in charge of the medicine rotation with a blank look that belied his jumbled thoughts. Since July, the clinical segment of medical school had overwhelmed him. Numbed and intimidated, Dan had gradually receded into silence, the worst possible position for a third-year medical student. Too disheartened to respond, Dan simply shook the attending's hand and returned to his team.
"Hey, Dan. How was your evaluation?" asked his intern in an uninterested tone. She did not consider Dan "star material" and was relatively certain she wasn't alone in her opinion.
"Fine,"he shrugged in response. He noticed a paucity of students. Most had been released from clinical duties after their evaluations. After a pause, he asked, "Is there anything I can do?"
"We've had two admissions," she replied, "and I've started working one up. The other is just a stable transfer from on outside hospital awaiting nursing home placement. Somewhere along the line, they discovered he was a veteran and shipped him here. If you could write him up before you go, that would be great."
Dan hid an internal sigh. On any other night, he would gladly have stayed late: two months ago, Dan's wife had abruptly moved out, leaving behind a painfully empty apartment. Having recently failed to distinguish himself as a potential doctor, however, he would have preferred to spend this evening at home, away from the hospital.
At the threshold of the new patient's room, Dan paused. Clearing his thoughts, he walked in with a cheery greeting. The patient's expression of subdued desperation stopped Dan in mid-sentence. Something was amiss. Digging through the transfer notes and old charts, Dan pieced together the patient's story.
Approximately two months ago, the patient had had a massive stroke that left him without control of his arms and legs. Unfortunately, the patient had also undergone tracheostomy tube placement several months prior to his stroke. Speech had been possible with a tracheotomy speaking valve, but the valve was now missing. Thus, he was effectively mute. To exacerbate matters, the patient had no known living relatives.
Catching up to his intern, Dan explained the situation and asked, "How do we get a tracheotomy speaking valve?"
"Write an order for a speech pathology consult."
"Yeah, but ..." On a Friday evening, a speech pathology consult order would require follow-up telephone calls. Each phone call spawned more phone calls, but Dan was determined not to allow this patient to sit through a mute weekend. Eventually, Dan located a speech pathologist, and the two of them found a speaking valve in a far-off storage room.
Returning to the patient, Dan carefully fit the valve onto the patient's breathing tube. Looking straight at Dan, the patient croaked out his first words since his transfer, "I want my last rites."
Startled, Dan bolted out the door in search of the hospital priest. With his busy weekend schedule, however, the priest had already left the hospital and would not return until Monday morning. Another priest was available on an on-call basis, but the patient's doctor had to designate the situation an emergency. The intern's response was firm.
"No. This man is stable. He'll make it through the weekend."
"You don't understand," Dan replied. "This man knows he's going to die." Dan tried his best to retain his composure, but being at the end of professional relationship that appreciated neither the urgency of the situation nor the Herculean efforts required on the part of a student to obtain equipment and religious counsel, he did not care how agitated she appeared.
"Look. It's getting late. You're free to leave. Oh, and ... youdidagreatjobthanksforyourhelpandgoodluckonyournextrotation." The intern's voice faded as she raced off.
Resolutely fixed on the task of helping this man obtain his last rites, Dan ignored her annoyance. Instead, he found a telephone book and marched to man's bedside. Unfortunately, the patient couldn't recall the name of his parish. He hadn't been to mass in years. Undeterred, Dan patiently waited as dusty memories were teased awake. An hour later, Dan telephoned a parish, located on a street that rhymed with "flower."
A sympathetic voice from the outside voice answered the phone, and this kind soul located the patient's name on the parish roster. With the Friday traffic, the priest would be delayed an hour and a half. Could the parishioner wait that long? As the man nodded a weary yes, Dan felt a surge of relief. He said good-bye to the patient and, without a word to anyone else, made his way home in the chill March night.
Saturday afternoon, Dan's telephone rang. It was his "ex"-intern.
"Dan?" she asked softly. "The priest stopped by last night. ... I wanted to tell you ... that is, to thank you .... You see, your patient passed away early this morning."
This was based on my friend and classmate Dan (not his real name) who never felt the need to publicize his story. I still thank him for allowing me to share it. .