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Music was the one thing that was missing in my life as a medical student. In my first year, I started performing for palliative care patients in the hospital and met dozens of patients. But there is one encounter I play over and over in my head.
She is the 57-year-old “lady with the bleeding trach” in the Cardiothoracic Intensive Care Unit (CTICU), one of twenty-two patients on the thoracic surgery service. As a third-year medical student on my second week of clinical rotations, I'm trying to learn about tracheostomy care. Today, her site is clean. She is sitting up and breathing comfortably. A few days ago, I asked my supervising resident about the metal tubes that snake out of her chest and into a box. He explained that it was her artificial heart, but that we need not worry about it; the cardiac surgeons and engineers were in charge of it. Looking at it today, I wonder: How exactly does the box connect to her heart? Why does she even need an artificial heart? Before I can ask my resident, my team starts walking. It's time for us to go to see our next patient.
Over the weekend, as a volunteer musician, I look over the palliative care music list. I'm surprised to see Emily, the lady with the trach, on the roster. Upon reading a palliative care note, I learn that she has been in the hospital for almost two months and that she may have only months to live. I decide to perform for her since I already know her from daily rounds.
I wheel my cello to her bedside. Her long, blonde hair tangles in front of her face, hiding her droopy eyes. I call her name, and she glances at me, slowly. To my surprise, she does not recognize me. I introduce myself as a volunteer musician and ask her if she would like to hear some music. I wait for a response, then feel my face flush as I realize she has a tracheostomy and cannot vocalize. After a pause and a long exhale, she nods.
I start unpacking my cello from my case, feeling the silence surround us, wishing the snaps on my cello case weren't so loud. Finally, I sit next to her with my cello. I've never sat so close to my audience before, with no music stand to hide behind, or stage to add distance. She is just two feet away from me, and I can see droplets of moisture gathering at her trach site. As I play, her eyes gaze at me emptily. I finish playing, and in place of applause, silence falls between us. I open my mouth but don't know what to say. She nods and closes her eyes, as if to excuse me –or did she fall asleep?
Questions swarm my head as I exit her room: Did she really not know me? How did she end up in the CTICU? What was her life like before this? Did I make her day any better? I realize that I know nothing about Emily other than her diagnosis. Was I doing medical school all wrong?
I learn through her chart that Emily was previously healthy, owned her own business, and walked five miles daily until a trip to Hawaii two months ago. She caught a cold there with runny nose, cough, sore throat, fevers and chills. She fainted once on her flight back home but didn't think much of it, until she rapidly became short of breath. Two weeks later, she was in the hospital on cardiopulmonary life support with a diagnosis of a rare autoimmune disease of the heart. Now she likely has only a few months to live.
Through the door during rounds, I see her clean trach site. It is not bleeding. She sits with her head down, eyes closed. For a moment, I'm afraid she will look up. I'm afraid she will see me—see the way I'm looking at her, differently than before, that she will see her sadness reflected in my eyes. I'm afraid she will see me not as the medical student on her surgery team but as the volunteer musician who felt raw and vulnerable before her, who left her room feeling unaccomplished and defeated by her suffering.
If she does look up, maybe I'll finally ask her: How are you? (Are you ok? You must be scared.) How can I make you feel better today?
But she doesn't look up. The engineers arrive to calibrate her artificial heart. It's time to see the next patient.
I remained on the thoracic surgery service for another week after this encounter, but I couldn't bring myself to play cello for Emily again; I didn't know if I could handle another experience that would make me question my training.
Over the next year of rotations, I became more confident in the hospital. I began taking ownership of my patients' care, combining my medical knowledge with empathy to provide more personalized care. Every so often, Emily's image comes to mind: Her blonde hair was matted. Her lips were gray and cracked. Her eyes were blue and beautiful. She was patient with me through my awkward musical performance. She persisted through her devastatingly long hospitalization. I bet she was a caring friend, a loving wife, and a reasonable boss. I wonder if she got a heart transplant and returned to her business. I wonder—though I don't want to—if she passed away. She taught me so much and guided my medical maturation without having spoken a word to me.
As graduation and the start of residency approach, I'm still working to balance objectivity and vulnerability, efficiency and empathy. As an internal medicine resident next year, I want to ask my patients to tell me one thing that is most important to them. A part of me still fears that they will tell me something that reminds me of myself, my friends, or my parents; that I will imagine my loved ones in similar positions; that I won't be able to provide the best objective care for them; or that I'll go home feeling deeply saddened, questioning my path. But it's a risk I want to take.
School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
Back to the January 2018 issue of ACP IMpact