heartbeak

August was my last full month of inpatient medicine at SFGH, our county hospital and place I feel most at home in terms of work. I was lucky to average 80-90 hours a week, having a relatively lighter load of patients than some of my colleagues working at the same time, several of whom had a slew of many 12+ hour days in a row. In the end, I think no matter how well your body holds up against this unhealthy amount of work, your heart inevitably breaks when spending a month at the General. Not because you feel more than slightly less than human when you skip meals and sneak candy to fuel yourself and can’t sleep at night because you’re too wired from the day and wake up even earlier than the before-light time that you need to because you’re worried—this is all true. But when things happen to you, you feel like you can make sense of them (whether this is actually the case, who knows, but you feel like you can). When you see other lives un-crumple and re-crumple, you cling to edges and cut your fingers, and these seemingly slight wounds pretty much broke my heart. In that concomitant temporary it-will-be-over-once-the-month-is-over and permanent lingering what-do-I-do-with-this kind of way.

There is so much dichotomy that the pieces you break into are often in battle with one another. In these patients lies the kind of stubbornness that inspire extreme awe in the power of people to keep going, and extreme frustration in how things can continue in the same way for so long. Their situations are so fragile, yet their dispositions so resilient, that you scramble to figure out what it is that you’re trying to support.

I had to near-force one homeless man in his seventies with terminal cancer and without family to leave the hospital, to slowly bleed from his illness on the street, because he’d exhausted all of the options for a homeless patient. This was not wholeheartedly the result of a system that failed him—it was, as many providers who cared for him deeply and knew him well, also a result of his own self-damaging perseverance in remaining homeless over going to a hospice facility. I was told by other providers, deeply kind providers, to consider our resources: our hospital beds, our shelter beds, our rescue centers are scarce and he had consumed much of them already, and we had to use our resources they were meant to be used, not to bend to the will of a charmingly, frustratingly independent patient who selectively discarded rules. His actions may have been for the protection of his family, or for fear of dying, but many rational, reasonable justifications were clouded in unyielding decision-making that I could understand but never truly feel. When distressed, his face was all wrinkles, and through these creases, eyes closed, he said to me, “How can I go, like this?” All through the morning, I demanded, then begged, him to leave early so that he would have the best chance possible of attaining a shelter bed (the lines start early). I had worked hard the night before to ensure that everything was ready first thing in the morning. He refused and refused, until by the time he finally left it was likely too late for him to find any refuge for the night. I offered him again the option of hospice, and again he refused, yet he wanted to stay in the hospital, where he no longer met any criteria to stay, where I had already fudged a note to cover an additional night. Spinning in this cogwheel taught me helplessness.

But, not only did I see the same type of hospitalization he’d had many times before unravel during my time with him, I saw it come to an end. The day after we forced him to leave, he returned, and made his way to hospice. Even when he made this decision, he didn’t make the way easy. It took me almost an hour to place a tuberculosis test on his arm, a necessary procedure before he could go to hospice. All the while he pleaded with me to leave him alone. I guessed that he was scared, of needles and of the idea of needing to be tested and the sense of actively dying. I ask myself after all this, what was it that broke my heart? The human resilience that caused such damage, or the act of it eventually giving way to the world?

I could be ironic and say the latter. But then I think of the young man with crippling untreated HIV with a severe brain infection who, when I meet him, refuses to speak to us. His co-existing psychiatric illness, homelessness, past trauma, substance use, and only he knows what else, makes him distrusting of us, and child-like in his assessment of the world. To him everything is unfair, and I grapple every day between agreeing without interfering, and wanting to shake into him some recognition of what he could still gain despite all that has been taken from him. We spend two weeks with him, daily administering medication that will save his life temporarily and daily trying to gain his trust so that he can live beyond this acute infection. We make strides: one day as we speak to him about a procedure needed to reduce his symptoms and treat his infection, he refuses to answer any questions and the only words he speak are to say that he will hurt us if we continue in our attempts to do this procedure; a few days later, he apologizes for his behavior. After awhile he allows us to do things he’d initially refused, like drawing his blood for labwork daily. Our medical student spends hours getting to know him, contacting the few people in his life, communicating with other providers taking care of him, bringing him his favorite foods, and trying in all the ways any one person can to validate him. On morning rounds, I underscore her efforts—look at how much patience and endurance can achieve.

But two weeks, though long in terms of a hospitalization, is short in one’s life. Minor things still set him off and off the course we’d try to reset for him. We work incredibly hard to find a safe place for him to go after leaving the hospital, and manage to get him into Medical Respite, a place for homeless patients to go after being discharged where they could be housed and could continue to attain any necessary medical care for a brief time. We are hopeful that they can help re-engage him in care, get his medications started for his HIV, and possibly get him into housing, which he cites as the main source of his problems. This was actually the place that the previous patient had most wanted to go to, but who could no longer take him given the scarcity of resources and their need to take care of patients like this one, with an acute need for medications. For several days I prime this patient for going to Respite; he is enthusiastic; he asks questions about where it was and what the rules were.

On the morning he is scheduled to go there, I’m paged by the nurse as I have been many a time before for him (“Refusing medications. Wants to speak about it.” “Refusing labs. Please see him.” “Would like chips.”). This time: “Upset that he cannot find his shoes. Refuses to go to Respite.” The shoes he had come to the hospital wearing have been lost, and can’t be found in our pile of donations. This angers him so much that he no longer wants to go to Medical Respite. He lashes out, falls back into the distrust that holds him back into a child-like view of how things work (centered on him, yet against him). I find it hard to believe that he can’t see how much we care, and I’m desperate. I find myself doing crazy things like offering to purchase another pair, which I know is both unproductive and damaging. It takes a long talk to convince him to at the very least take his medications with him, and he walks away without his instructions, his appointments, or a goodbye. After all the daily battles in trying to keep him in tact despite himself, the blocks I’ve built up inside of me to do this job slide out of place and I lose my shape.

At the end of the day and end of the month, I place faith in self-malleability, and know that even if I never retain the same self after experiences like these, the pieces are there and are mine to arrange. And that power is what I think people would want most for others, and what underlies this revolving door of the hospital. As much as the entrance and exit look the same, I hope with everything that something lies between.