High Noon.

So I'm past halfway through my third year of medical school and I don't feel like a doctor yet but I'll get there. I spent the majority of a bitterly cold snowy February on the internal medicine service at the VA hospital with veterans who were admitted frequently for CHF exacerbations, pneumonia, lower GI bleeds and hepatic encephalopathy but occasionally for more puzzling complaints such as inexplicable syncope. At the VA, almost every patient was male and over 60 years old with coexisting chronic diseases which only complicated their care (COPD/Diabetes). Most had been admitted to the hospital before and knew what to expect... a course on antibiotics, IV fluids, a paracentesis, maybe some extra dialysis sessions or a heavier course of their already complicated drug regimen. In most cases, the men who were admitted were treated appropriately and discharged in better shape, but as I wrote their discharge summaries I realized that it would not be long until they were back if they live long enough to get another tuneup. During the course of the month 4 of our patients became unstable, were sent to the ICU despite our best efforts to treat the illnesses we could, and then passed away. We knew that some of these men could not be saved, but we would consult the experts, adjust their medications, and compassionately discuss end of life care with them. Our patients' names would be mentioned briefly on rounds if they died in the ICU, and then they were quickly forgotten as we had too many living patients to dwell on those who had passed.

One morning in particular stands out on the second to last day of the rotation when our team was seeing a patient with ischemic peripheral vascular disease. We had been following him for about ten days, watched his fingers slowly turn black and were unpleasantly surprised to see his penis was doing the same. Surgical revascularization seemed like the only way to save his extremities, but his end stage renal disease made it difficult for him to receive nephrotoxic contrast agents to visualize his arteries. He received dialysis, a rheumatology consult saw him to rule out any puzzling connective tissue disorder, dermatology was consulted and suggested a condition which I know little about. After a week the patient was operated on by the vascular surgeons, but they were unsuccessful as the endovascular guidewire became stuck in the patient's severely hardened and calcific blood vessels preventing any stenting/balloon angioplasty. And then after "the million dollar workup" our team stood by our patient's bed, looked at his arms and penis, and realized that we were at the end of the line. Our attending physician explained that we were running out of treatment options; he stared out the window for about five minutes in near silence. He then explained to the patient that he would need to talk to the orthopedic surgeons to setup an amputation, and that the urologists would be consulted to insert a suprapubic catheter into this man's bladder because his penis would no longer be functional in a matter of time. I stood quietly through all of this, looking out the window trying to see if my car was covered by snow, and thought to myself that if the moment of silence was extended any longer all the orange sherbet in the cafeteria would be sold out and I'd be in the hospital long past noon on my post-call day...