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Dartmouth Medical School Dartmouth-Hitchcock Medical Center

Student Notebook

Turning point

By Erin Sullivan, M.D.

I felt a surge of nerves as I approached the last exam room of the day. This was a reunion for which I had hoped, even prayed. I had first met Sam, the patient in that room, two years earlier, on a stormy, wind-whipped Friday evening in 2009.

At that time, I was a third-year medical student on the medicine team. Sam was just a few years my junior and reminded me of my brother. He had been admitted from an ambulatory clinic, having been deemed too ill to return home. Soft-spoken and with a shy smile, he seemed overwhelmed by the flurry of activity that accompanied his arrival. Nurses and doctors donned masks, gowns, and gloves before touching him. We asked endless questions, prying into the private corners of his life. We traded his sweater for a hospital johnny and his LaCoste sneakers for nubbly, skid-free socks. A nasal cannula tethered him to the wall, delivering supplemental oxygen. His breathing was shallow and quick, his nostrils flaring and his neck muscles tensing with every breath.

The Student Notebook essay offers insight or opinion from a Dartmouth student or trainee. Sullivan, a DMS '11, is now a resident in internal medicine at DHMC. The patient she writes about gave permission for his story to be shared here, but his name has been changed.

I got to know Sam in the days that followed. He and I talked about college, reality TV shows, our families. I began to build a relationship with his parents, who were interested in learning about my experiences as a medical student. Spending a few moments in the company of this warm and loving family was a welcome break from the stress of my medicine clerkship. Against this calm backdrop, however, events were unfolding that unnerved us all.

Dire: Every day saw the return of another dire test result. Sam had high fevers and soaked the sheets with sweat. He soon became hungrier for air. First he grew winded walking to the bathroom, then shifting positions in bed, and finally even when he brushed his teeth. The nasal cannula was exchanged for a clear plastic mask that covered his lower face, and then for an oxygen mask with an inflated bag dangling from his chin. Sam looked more and more like a patient. The trappings of the outside world—his iPhone, books, and funky glasses—were relegated to a shelf and later placed in a neat white shopping bag that accompanied him as he advanced through a series of rooms, wending his way toward the ICU.

After caring for Sam for two weeks, I rotated off the service, but during my psychiatry and ob-gyn rotations my thoughts often strayed to Sam's ongoing struggle to live. Classmates who assumed his care kept me updated, and I visited whenever possible.

During my visits, I watched—from the expansive windows in Sam's ICU room—as the leaves turned to autumn splendor, then dropped from the trees. Soon the first snow blanketed the mountains surrounding the hospital. Every time I visited, I noticed big changes in Sam as well. On my first trip to the ICU, I walked right past his room, not recognizing him. His cheeks and temples were sunken, and he had a breathing tube strapped to his face. A growing number of machines populated his room, until he was connected to more pumps, drains, and filters than I'd have imagined possible. In the evenings, his room was filled with garish lights and beeping alarms triggered by his failing body.

As the weeks passed, the fog induced by sedatives grew denser, so that during my later visits Sam was able only to grasp my hand. Once, his eyes flickered open and rested on me, the corners of his mouth lifting ever so slightly before his lids drooped closed again. His father said that was Sam's first smile in a week.

Notes: My desperation mounted as his disease evaded therapy after therapy. Doctors' notes recorded Sam's deterioration, raising the likelihood of death from possible to probable to imminent. Sam hadn't wanted his friends and family to know how sick he was, but as he lay fighting for his life, his parents made the heart-wrenching decision to call his loved ones to his bedside to say goodbye.

My desperation mounted as Sam's disease evaded therapy after therapy. The likelihood of death was raised to imminent.

When I walked into Sam's room the following evening, the nurses had cleared the room of visitors for a few moments so that they could attend to him privately. But where before there had been signs of his failing health, there now was an explosion of life. Music was playing, colorful garlands of cards hung around the room, and the mirror was plastered with pictures from happier days—the family in front of a Christmas tree, three-year-old Sam drying his hair with his mother's hairdryer while he roared with laughter. My knees nearly buckled with grief.

I walked outside to find his parents, but the hallway was packed with unfamiliar faces. Someone asked if I was there for Sam. When I nodded, one of them murmured, "So are we," and about 30 despondent faces turned to look at me.

That day marked a turning point in Sam's status. In the weeks that followed, I checked on him every evening. Against all odds, he was holding his own. Eventually, there were subtle signs of improvement. One notch at a time, his mechanical support was dialed down and his tubes and wires were removed. It seemed to me that the most important factor in his recovery—even more important than the specialists' carefully titrated treatments—was the charge of energy that his loved ones had introduced to his care.

Embrace: Two years later, now an intern, I prepared to see Sam again. I opened the door to the exam room and was met by his embrace. I marveled at his pink cheeks and his self-described "paunch." He marveled at my new long white coat. It was an immeasurable gift to see his life in full bloom and to know that I was, and still am, part of the team that helped to save his life.

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