Finding My Calling in the House of Hope and Fear

Mr. Diverticulitis started having belly pain two days before coming to the ED.  He had the chills and a fever the night before and now he couldn't keep any food down.  The belly pain was no longer bearable.  He's a Cuban American from Florida who heard about a drug rehab program in Seattle while watching A&E.  He's been clean from cocaine for the last five months.  He's trying to start over and get his life back in order.



He was in obvious pain as I took his history.  "Okay, sir.  I know you are in a lot of pain, but I'm going to have to examine you now, get some blood to run some tests, and send you for an x-ray and CT scan of your belly so we can get to the bottom of this and figure out what's going on."

"Okay, ma'am.  Thank you so much for your help."

"Oh, you don't have to call me ma'am.  'Emily' would be just fine."

"Well, you called me Sir.  'Mr. D.' would be just fine."

"Fair enough, " I said.  I've made it a habit to call all of my male patients "sir" out of respect and as an 'out' if I forget their name.  As I cared for Mr. D., I found it very difficult to break my habit and each time I used "sir", he would quickly respond with a "ma'am".

Over the next few hours as we waited for test results, Mr. D. and I made a connection and I realized that he saw me (not my attending physician) as his doctor.  He asked me questions and looked to me for answers.  When the CT scan was finally read by the radiologist as 'uncomplicated diverticulitis', I gave Mr. D. his diagnosis, explained what it meant, told him what our plan was, and gave him discharge instructions including what medications he was to take to treat both the pain and infection and under what circumstances he should return to the ED (for which I usually just make up something that sounds good): fevers greater than 101.5, shakes, chills, vomiting blood or blood in the stool, and the ever so nebulous "worsening symptoms or concerns".  He thanked me profusely and told his ride that "Dr. Emily took great care of me".

Three days later I was getting an EKG and taking a history on a patient who was having chest pain.  Yevgeniy, one of my classmates, was in the patient bay adjacent to me talking to his new patient who presented with abdominal pain.  Through the curtain I heard a voice say, "Well, I hear Dr. Emily right next door, just ask her.  She knows what's going on with me."

I poked my head through the curtain and saw Mr. D., sweat dripping down his forehead, clutching his aching belly, smiling up at me.

"Mr. D.!  Hey 'man' (I remembered to replace 'sir' with a more informal salutation)!  What are you doing back?"

"Oh, Emily.  I'm glad to see you.  You said to come back if I didn't start feeling better in two days or if things got worse.  I'm not better at all, in fact, it's worse.  I had fevers, the pain is more intense, and I vomited a little bit of blood this morning."

'Wow,' I thought.  'Patients really do read those discharge instructions.'

Mr. D. was now Yevgeniy's patient, but Mr. D. still considered me "his doctor" and he thanked me again later that night when he was admitted to the hospital and taken out of the emergency room.


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Mr. Hypotension scowled at me as I swung the curtain closed behind me.

"Hello, sir..."  I introduced myself in the usual fashion.  "What brings you in today?"

"For god sake's!  I already told you.  How many times do I have to explain things around here.  Doesn't anyone listen to me?"

I was a bit taken back, "I'm sorry, sir.  I know you have told your story many times tonight, but I'm going to be taking care of you and I need to hear it myself."

"It's all there."

"Where, sir?"

"It's all there in my chart.  Don't any of you people read?"

I could tell I wasn't going to get far with Mr. H. if I continued with my traditional approach to patients (1/2 oz of sweetness and 1 oz of sincerity).  "Okay, then.  I'll make a deal with you: I'll go read your chart and if I still have questions when I get back, you have to answer them for me.  Fair enough?" (1/2 oz tough love and 1 oz bitch).

"Whatever, I guess that's okay."

I stepped out to the physicians' work station and smiled: Yes!  I LOVE cantankerous patients!!  These patients are SO much fun because they are a challenge and I get to play a game with myself where I try different tactics to approaching them in order to develop a rapport.  If I'm successful, I win them over and we are "buds" (which is when the real fun starts because then we have crossed a boundry and we can flip shit back and forth...it's not just the patient flipping it at me!).  If I fail, at least they were entertaining and it will probably make a funny story.

I read up on Mr. H.  He has multiple medical problems, but from the chart notes, I deducted that his problem was probably related to his renal failure.  He's on dialysis and recently had a port infection.  After being dialysized the day before, he went home and was feeling dizzy and lightheaded with position changes.  He was in renal clinic before being sent to the ED because he was found to have a very low blood pressure.  The top things on my differential were: 1) hypotension secondary to volume depletion from being over dialysized and 2) hypotension secondary to reinfection of his port and a possible bacteremia.

I explained my theory to Mr. H. and held him to his end of the bargain, asking him a few more questions about his symptoms.  His hesitancy and distrust of me gradually melted away over the next few hours, although he didn't stop giving me a hard time and I didn't stop giving him a hard time either.  We would occasionally glare at one another, raise an eyebrow, then smile just as I do to my evil arch nemesis.

I told him he couldn't leave until his blood pressure was over 100 systolic when he stood and he didn't get dizzy.  When he reached my 'discharge endpoints', he adamantly denied getting dizzy, but by this time I didn't know whether to believe him or not, so like he had to learn to trust me, I trusted him and sent him home.


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Ms. Found Down called 9-1-1, but couldn't tell me that when she arrived at the ED.  She couldn't recall what had happened to her.  Her eyes were swollen shut.  Blood gushed from her head lacerations that were over both eyes and the bridge of her nose and extended to her skull.  The Trauma Doc applied pressure and investigated the wound.  The R1s started IV's, drew labs, and quickly assessed her for injuries to her lungs, heart, abdomen, pelvis, and extremities.  I listened to the medics give report and to Ms. FD moaning in pain as her right arm reached for her head.  It was my first day on the trauma team and I wasn't sure what my role was.  How could I be most useful?  I extended my arm to hers and gently took her and in mine.  She squeezed in relief.  I immediately felt a connection with her, as if she was telling me that she was scared, that she was alone, confused, didn't know what happened, and that she needed the support my hand could offer, even if I was just a stranger.

As she stabilized and things settled down, I "picked her up" as my patient.  "Ms. FD,  I know you can't see me right now, but my name is Emily."  I took her hand in mine again and touched her gently on the shoulder, "I'm a fourth-year medical student working in the ED today.  I'm going to work with the team to take good care of you tonight.  You just let me know what I can do to make you more comfortable, okay?"

Her daughter arrived and ran to the bedside, slipping her own hand into her mother's, "Oh, my little Angel Mommy".  I saw Ms. FD squeeze her daughter's hand as she had squeezed mine only moments before.  Her daughter was able to give me a good past medical history and I would check in with Ms. FD to see how she was feeling: "How's your pain?  Do you need medicine for it?  Would you like another warm blanket."  Over the next hour I continued to keep Ms. FD and her daughter updated on test results and plans for admission.  I tried to answer questions as best I could, but I didn't know most the answers, so I did what I knew how to do:  I cared, I gently laid my hands on her.

When I went off shift that night, Ms. FD again squeezed my hand tightly and thanked me "for all I'd done" and her daughter hugged me.

"Bless you," she said.  "You are in the right profession.  I can tell this is your calling and you are going to make a great physician."  I left the room feeling honored and humbled.  Honored to have such a complement and humbled that in a matter of a few minutes I had gained Ms. FD and her daughter's trust and respect.


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I started a book today, "The House of Hope and Fear", written by Audrey Young, a Harborview Internal Medicine attending physician who did her residency at HMC and worked as a Medic 1 doctor in the ED.  She speaks of her experiences in the hospital and refers to it as the House of Hope and Fear because that is exactly what it is to patients: a place of fear of the unknown and hope for answers.

Over the last few months I have been doing a lot of soul-searching as I approach a deadline for making a career decision.  Last spring I narrowed my top choices to internal medicine and surgery. I loved being in the OR and doing things to help patients and I was told I was "a natural" when it comes to manipulating the surgical tools and performing procedures.  I had some great surgeons who became mentors and role models to me and I think those people drew me in to considering surgery.  After a lot of introspection, I realized that surgery doesn't "fill me up".  I know enough about myself to know that I can't do something for the rest of my life if I'm not filled up.

I committed to a decision this Thursday and I called Dr. Paauw, the Internal Medicine clerkship director and residency mentor, to set up a meeting to discuss appling to primary care internal medicine programs.  The thing that fills me up the most in medicine is the patients: being their doctor as I was for Mr. D., earning their trust and trusting them as with Mr. H., and providing a comforting touch in a time of need like for Ms. FD.