"All suffering is not equal" (May 17)

- Quote by Paul Farmer

Tuesday was a good day.  On rounds that morning, I called attention to a patient breathing 40 to 50 times per minute.  My recommendation was to obtain an urgent chest film to rule out a life-threatening pneumothorax (air in the lung that is pressing on the lung tissue and preventing it from expanding) after a procedure had been performed several days before to drain fluid from his lung.  Others on the team felt his symptoms were better explained by a possible infection and were comfortable waiting for the nurse to take the patient to radiology (which in my experience could take days).  This was too long, and I disagreed.  There were many patients on our service who I knew had little hope for recovery, but he was not on this list.  I excused myself from rounds and recruited someone to help me wheel the patient to radiology, shortly after which I was not surprised to learn the patient indeed had a very large hydropneumothorax.  We all agreed he needed a drain placed in his right lung to drain the air and fluid over the next several days, and I performed the procedure myself (my very first chest tube!).  There was an instant rush of air and almost a liter of fluid poured into the drain after the tube was placed.  The patient looked and felt better within minutes, and so did I.  I made a difference today.  I was proud of my education and training, and even prouder I trusted my instinct to save this man's life.

Many of my patients, however, are not this lucky.  This morning, after I had just pronounced the death of one female patient with meningitis, I was saddened to learn another patient of mine with liver cirrhosis had also just died.  Several days ago when he was admitted, I diagnosed with him hepatorenal syndrome and end-stage liver disease from chronic alcohol use and Hepatitis B.  But the hospital had none of the three medications used to treat this syndrome, nor the option for surgical transplantation.   I knew he was going to die, but it did not make his passing any more palatable or just.  I was angry.  All along I knew exactly what needed to be done for him but I was powerless to do any of it.  The satisfaction of my chest tube earlier that week now seemed like a distant memory. I could feel myself pulling away again, and part of me wondered why I even bothered to try for patients like him in a place like this.  Today was a bad day.

The answer to my confusion was in a book I was reading a few hours ago (on my flight to Kasane) by Abraham Verghese, titled "Cutting for Stone."  In it the Matron of the hospital says to one of her benefactors, "We aren't even fighting disease.  It's poverty.  Money for food, medicines…that helps.  When we cannot cure or save a life, our patients can at least feel cared for.  It should be a basic human right."  For the past several weeks I have become increasingly frustrated by the striking (and disturbing) differences in patient care between this hospital and those I am accustomed to practicing in at home.  While these differences are important and should never be overlooked, I can not let my frustration belittle and overshadow my most important responsibility as a physician, a responsibility that has no borders or boundaries or asterisks.  For my remaining time here, I intend to shift the focus of my care from treatment to doctoring.  In the words of Paul Farmer, I am "challenging my belief and desire to always want to think big as a reason for why I am not happy taking care of patients clinically on a small scale."

- Quotes from Paul Farmer in Tracy Kidder's book, "Mountains Beyond Mountains."