Mistaken or wise?
I read recently that the only people who don’t make mistakes are cowards and slackers. It’s not true. I’ve made many mistakes, and one that still haunts me was made because of cowardice.
I went to medical school in the Bronx, N.Y., at the height of the AIDS epidemic. Someone said then that in the North Central Bronx Hospital (NCB), where I did my clinical rotation, 90% of the patients had HIV, and 60% had AIDS. Whether or not that was exaggerated, AIDS was rampant, widespread, and (back then) an incurable death sentence. And at that time in the Bronx, needle sharing was most responsible for its spread. Back then, heroin abuse was a forgotten problem, mostly confined to the poorer, browner communities — communities less noticed by the mainstream.
Now, when I read a patient’s vital signs, I am reminded of one woman I treated back then. I’ll call her Carmen, a pretty, happy mother of two whose husband had infected her with HIV before he died. She was supposed to be only moderately ill with pneumocystis carinii pneumonia and was always happy — even proud — to see me, a third year medical student whom she was teaching through her illness.
One day, she started to look short winded. As I wrote my Progress Note, I dutifully copied the vital signs recorded by the nurse “120/80 (BP) 20 (respiratory rate) 80 (pulse) Afeb (afebrile).” Every day, the same vital signs. When I counted her respiratory rate, however, I counted 38 breaths/minute, not 20.
I was too cowardly to believe my own eyes and report what I saw, afraid of being wrong and looking stupid. I put more faith in the nurse’s recording than my own, even though every day they were the same “120/80, 20, 80, afeb.”
The nurses in NCB were overworked and understaffed, and I know now that they didn’t have the time to count respirations over a full minute. And at first glance of the ever-smiling Carmen, she seemed fine.
But after the third day of counting respirations in the 30s to 40s, I finally told my advising resident. Carmen was transferred to the ICU that morning, on a ventilator by noon and dead two days later.
She had a highly resistant bacteria, VAREC — VAncomycin Resistant EnteroCoccus. By the next day, several other patients on the floor were infected with the same. I know that had I had faith in my own observations and the courage to state them, she, and perhaps others, wouldn’t have died so soon.
We are in a different epidemic now. One that kills our parents more than our kids, and, of course, the poor more than the rich. Every day this week, I donned my PPE to enter COVID rooms. Today, I once again saw a patient I have known a long time, someone who had been doing well despite his heart problems. But now he was on a ventilator with COVID pneumonia. Septic shock. COVID myocarditis. Remdesivir. Dexamethasone. Levophed. Lovenox. Aspirin. Medically paralyzed so he won’t fight the vent.
At night, I sent a group text to my family saying that this year my wife Carla and I wouldn’t participate in Thanksgiving or Christmas. No apple pie. No singing. No laughing. No lasagna or pumpkin soup. A hard thing to do given that getting everyone I love together in a room is getting increasingly rare, that we are getting increasingly older, and that, year after year, the older generation seems to be getting fewer and fewer, even as I find myself becoming one of its members.
I really don’t really know if not seeing my family these holidays is cowardly or bold, mistaken or wise.
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