Wings of an Angel

By Shanup Dalal

It is said that you will never forget your first patient and your first patient death. Ms. X was one in the same for me, but I will not forget her for much more. I remember an air of nervousness overwhelming me as I walked down to the emergency department to see her. As I entered the room, I saw her lying motionless, with only her lips moving as she mumbled incoherent words. She was in an altered state of mind, more so than her usual baseline of Alzheimer's. Upon asking her daughter some questions, I began to paint a picture of the strong woman Ms. X used to be before her Alzheimer’s, a single mother who raised her 8 children alone. More importantly, I began to piece together the puzzle of what caused this acute presentation. The daughter began to relay how her mother was having burning upon urination and a subjective fever in the days prior to this ED visit. The story continued, and all signs began to point to a complicated UTI leading to her altered state.

Ms. X was admitted that evening to the telemetry unit, where we realized she had an abnormal heart rhythm most likely due to her heart medication. Her medication was immediately stopped, but her atrial fibrillation returned as she became hemodynamically unstable, worsening her clinical presentation. The cardiologists and internists were at a stalemate when it came to treating the patient’s cardiac symptoms. The cardiologists wanted the patient placed on amiodarone, a medicine with more severe side effects than the Sotalol the patient was currently on. Whereas the internists were worried amiodarone would worsen the patient's underlying pulmonary and thyroid problems, the cardiologists were worried the sotalol would worsen her atrial fibrillation. Through these disagreements, the patient's condition continued to worsen, and the physicians began to truly neglect Ms. X. She began to clench her blanket between her teeth, as she squeezed my hands as hard as she could while crying during her physical exam. She was in pain but was not receiving any pain medications because the physicians believed her most dire problem was her cardiac state.

Something needed to be done. However, what could a medical student with limited clinical education do? It was not until the next day when Ms. X cried during morning rounds that I immediately turned around and went to my chief resident to ask that she order pain medications. Surprisingly she was not angry, but asked “What would you like to give her?” Though shocked at first, I proceeded to state what hours of research led me to believe: “Withdraw the morphine because it would worsen her hemodynamic instability, and provide IV acetaminophen.” Two hours later, nurses administered IV acetaminophen, and she began to show signs of pain relief. To everyone's surprise she began to speak to her family the next morning. This turnaround was not expected, especially by Ms. X's daughter who stated, “You doctors wear white coats that are like the wings of an angel. You all are my mother's angels.” That evening, Ms. X had her last breath. Her pulse raced into the 150s, and she became unstable once again, ultimately passing away. Ms. X had a moment of clarity before she passed and was able to say her last words to her family. I will never know how it was possible for Ms. X to make such a drastic change in a few hours and then pass away the following day. However, I do know that she was not in pain in her last few hours.

I have quickly learned that we, as medical students, have the unique opportunity of getting to know patients on a deeper level than most physicians because of the amount of time spent with the patient. Empathy is something all medical students possess; it just needs to be practiced. To do so, students must be able to approach attendings without fear of judgment. It must be stressed that student input is welcomed and encouraged. In doing so, we will not go into residency believing we are angels that are meant to save patients. Rather, we will begin to see ourselves as human beings helping other human beings. We will begin to realize our white coats are not wings of angels, but rather a privilege that gives us the means to enter the world of the patient. If we learn to convey the information we garner from patients to physicians, the care for the patient will be much more geared towards all of the patient's needs rather than one aspect of it. In addition, we students will begin to develop into physicians who will actually see the patients for who they truly are and not only view them as another dollar. Through Ms. X’s teachings, I now know that our fear should not cloud our clinical judgment and that we should become the voice of patients when they do not have a voice of their own.

Shanup Dalal, M.D., Class of 2016, is a third- year medical student at UTSW who will be applying to med-peds residencies. The opportunity to treat a patient’s illness, in addition to the psychosocial problems the patient faces, is what drew him into medicine. He believes that in order to truly treat a patient a physician must not only look at the illness, but also see the patient as a human being who needs someone to listen. The reflection essays he writes are not only to satisfy his rotations’ requirements, but to serve as a reminder to himself that a white coat is a privilege that gives physicians the ability to help patients.