trust

A reflection from week 1 of the IM rotation

Mr. H had an acute kidney injury. No one trusted Mr. H when he said he didn’t smoke meth recreationally and that he accidentally smoked meth the night before on a cigarette he bummed from a friend. No one trusted him when he said he had relentless chest and neck pain on hospital day 1, day 2, or even day 3. (“It’s just because you’ve been vomiting and have sore muscles now,” he was told.) When discussing his case, many of the physicians working on his case scoffed and jeered at his story, his complaints. Sly smiles, dripping with derision, smeared on the young doctors’ faces. “They’re all liars,” a resident expressed, shaking his head in disapproval. “Why do you say that?” I asked. “Because drug addicts are liars. They don’t want to admit that they use drugs, and they won’t tell the full story. I learn more about these people by reading their charts when they arrive in the ED than I do from talking to them.”

By hospital day 3, none of the physicians wanted to spend more than a few minutes checking up on him in the morning; the intern stayed long enough to ask if Mr. H experienced any more nausea, vomiting, and anuria overnight. When Mr. H began to talk about his chest and neck pain, the intern left the room. “I have other people to see this morning, so I’m going to go,” he told me quietly before he slipped out from the room as Mr. H was talking. I stayed behind to ask Mr. H to elaborate on his pain, its character and location exactly. I wasn’t convinced that he simply had sore muscles, despite the fact that when I pressed on his chest, he winced in pain as if his chest was very sore– something that made sore muscles seem likely. Upon asking, he described his pain as sharp, internal, and accompanied by “crackling” or “bubbles” in his neck. I felt his neck. Under my fingertips, his skin danced as if it was resting on a water bed made of crumpled tissue paper. It audibly crackled. I may be a spring chicken, but I know that that finding on physical exam was anything but normal. I presented his case during rounds, to the mild disinterest of the doctors on my team (only interested in the part about whether or not he could be discharged that day), and noted that I’d like the attending to check on his neck because I found it to be strangely crackly. “Was it crepitus?” the attending asked suddenly looking more alarmed. I thought to myself, “Crepitus… What is crepitus…?” as I looked at her blankly. “Um, I’m not sure I know what that is.” She said she’d check it out.

He ended up having a pneumomediastinum likely due to an esophageal perforation that caused air to become trapped in his chest and neck– a finding that is termed “crepitus.”

I was lauded by my attending for my finding. I started hearing from other senior doctors in the hospital that they were also impressed with the finding. One of my later attendings told me that I should feel proud for performing a thorough physical exam, paying attention to the patient’s concerns, and finding the sign of his pneumomediastinum (a pathological situation that could’ve been much more consequential for him if his perforation had not closed up spontaneously!). “This isn’t something many of the residents would do; they’re too busy to stop and perform a thorough exam.” He continued, “Let this be a lesson to all of us.”

Perhaps this experience is not simply about taking time for patients, taking time to be thorough or to follow-up on complaints or odd findings, to not anchor ourselves to the easiest explanations. Perhaps this is also a lesson in trust, non-judgement, humility, generosity, and compassion. What greater gift can we give to someone than our time, attention, and thoughtfulness?

On that note. To all the addicts, people experiencing homeless, and those who are otherwise considered deplorable in the eyes of others: you matter. I hope I never stop trusting you when you say you’re in pain. I vow to maintain a sense of generosity of spirit and attention with every patient no matter who they are.