It is 8 p.m. Two hours remain on my final shift in the Emergency Department. The lobby is full and we are working at a fast pace. My preceptor asks me to go see the patient in bed three. A ninety-something-year-old man with chest pain.* I know the routine. I jot down a few notes, including a differential diagnosis and a list of labs and tests that I will likely order with my preceptor after interviewing the patient. I hop off the counter height stool at the nurse’s station and stride with the confidence of a student on her last day of a rotation toward the patient in bed six.
I draw the curtain, smile, and introduce myself to the patient first, and then to his adult daughter who is at the bedside. I am calculated as I speak more slowly and clearly than I normally would; it is loud in the chaotic ED and this patient is wearing hearing aids.
I interview the patient about his symptoms which are far more vague than the words “chest pain” initially led me to believe. He has been feeling ill for days. He has abdominal pain, nausea, and shortness of breath. His skin is pale and his tongue is dry. He can answer the slurry of questions used to evaluate his mental status, but more specific inquiries about his symptoms are met with “I don’t know.” His daughter looks increasingly concerned, and she begins chiming in to clarify the details of the events leading up to his arrival in the ED.
I conclude my exam and assure the patient and his daughter that I will return shortly. I present his case to my preceptor. This patient is far sicker than he or his daughter realizes. As the results of his studies appear in his chart his diagnosis becomes clear. Just as Occam’s razor dictates, all symptoms can be attributed to a single cause.
In the coming hour his health rapidly deteriorates. Despite our interventions his fever rises while his blood pressure falls. It was as if he read the textbook; before his symptoms and complaints were scattered, he now clearly resembles a patient of his diagnosis. And his prognosis is not good.
There is one hour left in my final shift in the emergency department. The elderly male patient is incredibly sick. He is floating in and out of consciousness, intermittently moaning with discomfort. Given his age, his comorbidities, and how quickly he has deteriorated, his treatment options are limited. The admitting doctor, my preceptor, and I step into his room to discuss these options with the patient’s family. He has five children, and they are all gathered by his side.
The children, all in their 60s, are heartbroken and confused. Their father lives independently and was fine just days ago. Now three strangers are talking with them about aggressive interventions versus comfort care, and all that lies in between. They are unsure how to best proceed. They briefly step out of the room to have a family meeting. The hospitalist exits to see another admission. My preceptor and I are now alone with the patient. There are dozens of pairs of running shoes swiftly passing back and forth on the other side of the curtain, but from where we stand, there is a stillness and a quiet.
The patient opens his eyes. His blood pressure rises just a hair and the knot in my throat lets up for a second. Perhaps this is survivable. My preceptor appears surprised to see him looking so alert and inquires, how would he like us to proceed? After all, this is his life, this is his body. In a lucid moment the patient explains that he is not afraid of death. He then goes on to acknowledge that his passing will be hardest on his daughter, the only girl of his five children. Then, with a slight upward curl to his lips that barely resembled a smile he shares his wishes.
The family begins to trickle back in. With the patient still lucid a decision is reached and care is directed toward his wishes. My preceptor steps out to place orders, and I am left in the calm behind the curtain with the patient and his family. I pose a simple question that I have been taught to use after providing patient education; “what questions do you have?” At first my words are met with silence. And then, one by one, family members speak up. They feel comfortable with the decision that has been reached, but they want to better understand their father’s illness. They need more information. I spend much of the last hour of my shift sitting with the family, explaining complex anatomy, physiology, pharmacology, and surgery, in the simplest of terms that I can.
At a certain point I sense that the family needs to be alone. They have run out of questions. Their glances are increasingly fixed on their beloved father. I quietly excuse myself and step out into the bright lights and chaos of the emergency department floor.
On my first day of PA school I was told that my training was a tremendous privilege. At no point over the past 18 months has that been more apparent than on my last shift in the Emergency Department, with that patient and his family. I feel so honored to have met this kind man and his children, and so fortunate for the training that allowed me to support them through this challenging time.
*Identifying details of the patient have been changed to protect anonymity.