Promise

It had been an amazing week in the mountains.  We had successfully planned, recruited, supplied, hiked and hosted a truly mobile medical clinic hiding among the clouds near the Dominican border.  We saw nearly 300 patients and had to unfortunately turn many away due to resources.  To say the Haitian pastor who hosted us was ecstatic would be an understatement.  I would say he is still grinning, but that was two and a half years ago.  And I haven't been back.

The plan was to make the trip every 6 months.  Recruit a dozen or so medical volunteers of various backgrounds willing to make the half day hike to sleep on a concrete floor in the Haitian mountains, backpack all of our food/meds/clothes up and down the two mountains, and provide medical care where no others do.  The 'team' walked back to Gran Bois with that understanding...And I wonder at what point the pastor realized that he would likely never see us again.

Here come the excuses.  We didn't have the support and infrastructure to continue the clinics.  Our Haitian connection to the location soured his relationship with Dr. Leo.  It gets expensive to fly to Haiti multiple times per year, hire interpreters, buy meds, etc.  And needless to say you'd need a large population of potential volunteers to recruit from.  And the time to recruit them.  When we are pulling 80 hour weeks in Wesley Medical Center it's tough to find the time to do these things.

This situation isn't unique.  Unfortunately the empty promise to return is often the norm rather than the exception in Haiti.  At this point I'm sure the Haitians are more surprised if someone does return than they are disappointed that they didn't.  Voluntourists are nothing if not genuine in their words - often filled with a new found sense of purpose and the joy and peace that brings.  As they walk into the Haitian airport their only thoughts are on a return trip.  Sadly many never set foot in the country again.  Life happens.  Other commitments, financial and time commitments, happen.  Kids.  Family.  Work.  Soccer.  Fantasy football.  And their "promise" is broken.

As a physician, I've learned not to make promises.  Speak in generalities.  Vagueness is your friend.  Speak with confidence but without commitment.  When you break a "promise" as a physician it's the same as being wrong.  And if you know me, then you know I hate being wrong.  All physicians hate being wrong.  It extends beyond risk of litigation.  It shakes your confidence.  If you're wrong now, you could be wrong with your next patient.  In sports they always talk about having a "short term memory".  I've found, in medicine one tends to remember every single time they've been wrong, forever.  Every promise made.  They all have faces.  Each failure has a face.  The families have faces.  The parents of the sick child have faces filled with fear.  And then you tell them their baby will be fine, and pray that you're not wrong.  Every picture sticks with you.

I broke my rule recently.  I haven't made a promise to a patient or their parents since Bedica.  And promised myself I wouldn't again.  I hate being wrong and I hate hate hate breaking promises.  As a physician, a promise is an unnecessary commitment to an unpredictable outcome.  And I can't 'break' what I don't make.  The case was a 30 year old male with what we thought was an odd fungal infection in his lungs.  I started providing his care a couple days into his admission.  My checkout was "young guy with what we think has histoplasmosis".   "Dr. Moore is consulted."  You may not know this but Dr. Moore is quite possibly the smartest doctor in Wichita.  So hearing this, I mentally check the patient into the back of my brain.  I've got plenty of other patients to keep my brain power occupied.  This one is what we call #ConsultedOut.  That's when you have enough specialists on the case addressing the critical and active needs that as the primary hospitalist you can just be like #Whatevs.

He wasn't getting better.  Every day I'd round on him and and his spirit was strong, but his body more worn.  Breathing a little heavier.  Sweating a little more.  But always smiling.  Room air.  Then 1 liter O2 per minute by nasal cannula...  Then 2-3 L by NC.  In retrospect my notes really foretold the impending decomposition of my patient.  People on the right treatment tend to get better, not worse.

He asked me, "How am I doing."  "You're doing great.  Keep up your strength.  Work on deep breaths.  Keep eating.  You have one of the smartest doctors in the state on your case."  No.  I wasn't referring to myself.  "Is this cancer?" he asked.  "No.  It's an infection."  #Confidence

We bonded.  We saw each other daily.  We were at very different places in our lives, but we were the same age.  Every day he asked me how he was doing and every day I offered reassurance.  Every day he asked me if it was cancer.  Of course not.  How would a 30 year old without any risk factors get cancer?  It didn't fit.  His history didn't fit.  His imaging didn't fit.  "We are just waiting on these tests to come back to confirm which infection it is."

He was moved to the ICU in the early evening.  "Am I going to get better?"  "We think so."  He could no longer speak with any strength, so he had to write his questions.  "Survive?"  "We think so..."  He immediately called me out.  "Think?" he wrote on his paper.  My confidence must've checked itself at the door.  He saw the concern in my eyes.  "Cancer?" he asked again.  "No."

Biopsies would prove me wrong.  He was subsequently intubated.  And even while intubated, and on heavy sedation he would ask me the same questions.  "Survive?"  "I hope."  He wouldn't stand for it.  His watering eyes told me he needed confidence from his doctor.  He had a wife and several children.  He needed confidence from his doctor so that he could have the hope.  Yes.  Me.  The least important "doctor" involved in his care.  The resident of his hospitalist team.  By this time he had accumulated a cardiologist, a pulmonologist, a nephrologist, an infectious disease specialist, and a hematology/oncologist.  My notes had detailed problem lists, but if I'm being honest the "problems" my team and I were managing were nutrition through a tube in his nose, preventing blood clots, and a making sure he pooped.  #VeryImportantStuff

I did it.

"Yes, you're going to survive.  Our goal is cure... I promise we are going to take care of you."

I've been sick ever since because I didn't believe my own words.  I walked into his room filled with a sense of guilt, failure and shame.  His mother must've hated me.  She suggested early in his course going to a different hospital.  I'm sure my incompetence has done nothing but reinforce those doubts.

It wasn't long until he couldn't ask me any further questions.  His body finally relaxed into the sedation.  Of course, I wasn't my usual, upbeat self heading into his room.  I timed it during nurse shift change when visitors were asked to leave.  I didn't tap on his chest to see if he would wake up and follow commands.  I used an inside voice to "ask him" how he was doing.  No response.  But I knew how he was doing.  And I knew I wasn't strong enough to stand in front of him and ask him about it.

His family elected to try a dose of chemotherapy.  Chemotherapy is an acute toxin to try and address a problem for long-term gain.  My patient wasn't able to tolerate the acute toxin.  His breathing worsened.  He went into arrest.  He's young.  This isn't supposed to happen.  And I wasn't supposed to feel.  He's a patient.  I'm a doctor.  I assess his problems and I prescribe medication to fix him...or find smarter doctors to prescribe medicine to fix him #MostOftenTheCase  

Chemotherapy was off the table.  Steroids weren't making any improvement.  We had "exhausted all available options".  There is nothing more humbling as a physician than walking into a patient's room - surrounded by the same family who witnessed Mr. Smooth and Confident throughout their loved-one's stay - and having to deliver the message that the dozens of doctors involved cannot fix what is going on.  It's crushing.  It's devastating to the family and it's miserable to the doctor delivering the message.

He passed away shortly after that conversation.  A thirty-year-old life taken away by an aggressive form of cancer he neither earned nor deserved.  A thirty-year-old physician again humbled by how limited "modern" medicine truly is.  And another reminder of the power of a promise.