Don't Eat My Eggs

I have always known that if I was ever going to share anything in writing I would begin with this story. I was forever changed for the better and it began in the first days after I graduated from medical school.

I selected an obstetrics and gynecology residency which involved four years of continued medical training after medical school. Most of the first year was spent working internal medicine rotations and just weeks after graduating I became an intern on the internal medicine service at the VA Hospital in Memphis. There were four level-one interns, and our job was to rotate admissions from the emergency room into the hospital every third night where we were designated to stay for 24 hours. Each admission was a patient we were individually responsible for on the service and on most nights we would each obtain about four to five new patients.

Once we were assigned a patient, our job was to obtain a full history of what was going on, perform a complete medical physical exam and order and review labs and other indicted procedures along with any appropriate medicines. There were upper-level residents overseeing our work and a hospital staff physician, "the attending" who was ultimately responsible for everything any of us did.

The priority in all of this was to provide the best and safest care for any patient. The structure was to simultaneously provide medical training for all of us. So, on my first day, just weeks out of school, I began this rotation of patient assignments. On the next mornings after working all night, and on every morning between; I would walk down the hallways with a group of doctors and present my patients one by one as we entered their respective rooms. I was asked to keep and carry individual index cards with the patients' names and admitting diagnoses and I would generally have six to eight patients at any time in this rotation because of concomitant admissions and discharges.

This internal medicine service was scheduled for two months. I began July 1st. And on that first day I was told that on August 1st all the interns would pass each of our index cards to another and we would all assume new patients on that day so that our experiences would more challengingly broadened.

Let me also explain the intimidation of our daily rounding routine. When I admitted a patient, I spent up to two hours charting the history and exam and labs and forming a plan for treatment. This was way before computers. If morning labs were drawn, I needed to secure those results even if that required walking to the physical lab to obtain them. And when our group entered my patients' rooms, I would present this information in a standard verbal format. I would have memorized all information including any lab and test results and concluded this information with a plan for "what's next?"

There was, of course, a large binder with multiple divided sections for each patient which was placed on a rolling cart which accompanied us while walking into each room. The process was intimidating. The attending would look over the notes and labs and the medical orders for any patient. And the game was wide open. The attending might ask me for a certain lab value, and I needed to be ready to respond promptly and accurately. I might be asked about certain medicines, why used and why others were not. I was grilled on any side effect potentially related to that medicine all while being watched by our group. If someone was admitted for hypertension out of control I might be asked anything in general about hypertension whether it was relevant to this patient or not. This was a teaching process.

I mentioned before I graduated first in my medical school. And I emphasize that I was by no means close to the smartest person in my class, but I was and am willing to work hard. So, throughout this process of admitting patients into the hospital and overseeing their care I took the work responsibility very seriously. And I wanted others to know I did. While doing morning rounds, whenever any of us were asked questions about our patient by the attending inside the patient's room with a group standing around the bed; it was acceptable, but frowned upon, to have to take the chart and look for that answer.

So, it logistically came down to this. If there was a patient admitted with only hypertension then that was equivalent to having one patient. If the same patient had diabetes out of control, then that was the equivalent of having two patients since each disease was a topic for teaching on rounds and required studying and prepared diligence. Fortunately, most patients had single diagnoses when admitted so six patient index cards might be the equivalent of having 8 patients.

Before formal morning rounds each of the interns needed to get to the hospital to prepare for this rounding process. For every patient diagnosis, we would need about fifteen to twenty minutes to gather updated information and test results and be certain that we and the patient's chart was updated with all of this. Rounds started sharply at 8 am. All this pre-rounding preparation could be comfortably completed if each of the interns arrived around 6:30–7:00 am to get the work done.

My first night in the VA hospital on July 1st, my first patient was a transfer from another VA hospital to ours. He was a man in his late 50s who was on blood thinners and hit his head on his home shop cabinet and didn't realize it was sufficient trauma to cause a brain hemorrhage and subsequent coma. His accident had occurred months before his transfer and he had been managed in another out of state facility until his breathing worsened. He required ventilation through his tracheostomy which had already been surgically placed and the transferring hospital did not have capabilities for his ventilation management.

He had been in a comatose state for months. With lack of movement, he had developed stasis pressure ulcers on his buttocks and legs and there were two areas where his bones were exposed. This patient was not a single diagnosis or even two. He was like having 10 patients: Coma, stroke, pneumonia, artificial ventilation, sepsis, wound care, tube feedings, etc.

I arrived at the VA hospital every morning at 4 am. It took me at least 2 hours just to get his chart updated and his existence offered an infinite possibility of discussions. The hospital hall lights were on automatic and did not even turn on until 6 am. I traveled down a long hall to his room holding a flashlight each morning. He was a great "teaching patient" for the attending to ask exhausting questions. Every organ in his body was affected.

He had daily chest x-rays which necessitated trips to radiology to see the scans. He had sputum cultures, blood cultures, wound cultures almost daily, and a host of abnormal lab values secondary to all his medical problems. Gathering all this was like herding squirrels. And I was determined to be "ready for rounds" on any morning. I still had other patients who required the routine 15 to 20 minute preparation. But I was at the hospital every morning at 4 am. And honestly, I resented that; but no one, no anyone would ever know I did.

It was obvious that this patient would never be discharged. He would be my patient for the entire month. He required more work each day than the accumulation of all other patients did the entire month. And all I could think about: "On Aug 1, someone else is getting this index card". I can keep my professional focus and responsibility till then.

Aug 1 arrived and my eagerness paralleled a kid wakening on Christmas. I went into our meeting room to join the interns for the anticipated index card swap. Not usual, a hospital administrator and my attending were talking. They called me over. And said: "The interns are all about to change patients, but this one patient has too many severe issues and it would not be fair to him to lose continuity in his care. You need to keep that card and not pass."

I looked at them and said: "Of course, I understand, thank you". And smiled.

And I was devastated on the inside. Pissed. I had managed to be at the hospital every morning at 4 am with energy fueled knowing it was almost over.

I never complained to anyone but me. And some days on rounds my attending would grill me like I was on the last round on a national spelling bee with the most complicated questions. And I spelled the word every time without hesitation. Without his chart. And as days passed, we often walked into this patient's room, said nothing and commonly remarked: "I can't believe he is still alive".

I'm not proud about what I did next, but I believe the statute of limitations has passed for me to be charged by the VA hospital for back pay for stolen food. Every day I went into this patient's room there was always a pamphlet asking: "what would you like for breakfast, lunch and dinner?" And I just smirked and thought: hospital people, can't you see he is in a coma, doesn't move any extremity, is kept alive on a ventilator and has protein juice going through tubing into his stomach? I just threw those pamphlets into the garbage for him. Until I didn't.

So, I filled out: "I would like scrambled eggs and sausage for breakfast" and left it there in his room. At 6 am the lights in the hallway came on like they always did and there followed a breakfast tray with scrambled eggs and sausage.

I decided to order lunches and return to his room at lunch time to do chart work. And I realized I could use his room as my private office for charting instead of the interns' meeting room where all us usually worked. His room was more peaceful. I could focus without interruption. I ordered "waffles" which were "special request" with my eggs and sausage and even ordered "milkshake please" which arrived every time with a note: we have vanilla, chocolate and strawberry. And I used my flashlight to work until 6 am when the lights came on. But I stayed in his room until rounds started at 8. I left with a very full stomach.

Arriving at the hospital at 4 am was/is never easy. And I still resented that my patient volume was at least double anyone else's at any time because of this one patient with "too many diagnoses". And I calculated a strategy for ME. If I was able to remove his need for ventilatory support I could transfer him back to his state VA. That was the critical issue in his transfer to Memphis. He was breathing on his own for some time after his accident.

At no point in this patient's care did I ever feel I wasn't giving him the best. But in my calculated strategy I decided to go above and beyond with only faint hopes of getting him breathing without assistance. He had open sores exposing bones. This alone was a constant source for infection and sepsis. It was customary for a wound patient to go to "whirlpool baths" perhaps once a week. I ordered him whirlpool baths daily. He was always susceptible to pneumonia, and it was customary to have pulmonary therapists do chest percussions once every day or two. I ordered them three times a day: every shift. This patient was always on antibiotics which were now fighting organisms mostly hospital acquired. There was a new 3rd generation cephalosporin which was not yet on VA formulary, but I went to a hospital pharmacy review board and asked for the exception. I spoke to his nutritionists managing his tube feedings encouraging higher protein concentrates with less volume to lower the risk of aspiration. New wound care options were being introduced, and I aggressively requested these. Pneumatic air mattresses were brand new and I managed one to his room. And all the while I was eating a breakfast of champions and a ridiculous lunch of special orders for my palate.

And the day arrived. Perhaps 16 days into the second month of my medical albatross and I was able to disconnect the ventilator so this comatose patient could return to his state VA. He was breathing without assistance. That is all I needed to begin the necessary paperwork for his discharge. Anyone familiar will understand this would not occur for a few days.

Per usual I arrived with my flashlight to sit in his room and chart for him and my other patients. My breakfast arrived like a fancy hotel. And I stood up to remove the silver dome and stared at my previous day's selections steaming on its plate. And I picked up my fork leaning over his bed towards his unnecessary, but necessary for food, bed tray. And I had a forkful of scrambled eggs and right when I put it in my mouth, I heard a robotic voice: "Don't eat my eggs!"

I think I dropped that fork with the exact same precision anyone would who thought God was speaking directly to them. And when I looked at my patient, he was holding his left hand over the hole in his neck where his ventilator was previously attached. This enabled him to sound his voice.

I waited for rounds to show him off when we all walked into that room together. My patient who has never been awake, who has never moved on his own, was sitting up in his bed holding his throat and said: "Good morning" to each of us. He robotically said to the group: "you all sure talk about me dying a lot". The joy was/is indescribable. His recovery: nothing short of a miracle. He did not get transferred to his state VA. His family drove to pick him up and I met them all in the parking lot where patients were picked up. He was in a wheelchair too weak to walk, but alert and engaging. I walked over to greet his smile, and he grabbed me with both arms — hugged my neck and said: "thank you, it's ok, you can eat my eggs."

This experience was the first 7 weeks after medical school. Rarely a day goes by I don't think about him and all of that. And how it is so easy to become complicit. To forget what God can do in all of us. To remind myself that the seemingly unjustifiable work can be so justified. To remember it is easier to give up instead of giving. That when it seems too beyond, sometimes going to beyond brings beyond to you. And that love comes in many forms and designs. But the crown is God's love for all of us. The only doctor we can really count on for every set of rounds.