Portal de Periódicos da CAPES

‘Do You Know Who This Is?’

2020; Elsevier BV; Volume: 134; Issue: 2 Linguagem: Inglês

10.1016/j.amjmed.2020.09.016

1555-7162

Jyotsna Ghosh,

"Urosepsis" was the diagnosis for the small-framed gaunt man who lay motionless as a mummy in the white sheets. Mr. Williams, 90 years old, had been in an assisted living facility because vascular dementia had left him unable to care for himself. "He's full code," my colleague told me during sign out. "Despite all the antibiotics we've given him, he's just not showing any improvement—he can't even raise his hand. I talked with Junior, his son, about life-saving measures and asked him to discuss them with the team today. To me, DNR is the right choice at this point." I reviewed Mr. Williams's labs—abysmal. He was somnolent, his thin eyelids fluttering but never opening. He did not respond to questions or to stimuli. Nasogastric tube placement had been attempted three times, without success. A swallow evaluation was impossible. "You just want to give up on him?" Junior Williams asked plaintively. "I'm not the one to decide. Mama is the one needs to give permission. Pop and Mama been married 68 years. She's been riding 35 minutes each way on the bus to visit with him an hour or two and has not missed one single day in two years. She's pretty salty about this virus, too. Hospital won't let her in, seeing as how she's 95." He chuckled a little. "Yeah, when I say 'talk to Mama,' that really means 'listen to Mama.' That's the Williams family rule." The COVID-19 pandemic meant that "listening to Mama" would have to be by telephone, and I called Mrs. Williams as soon as I could. I introduced myself and explained her husband's condition and our concerns. "You put James on the phone," a thin, but firm voice instructed. She doesn't understand that's impossible, I thought. Maybe I wasn't clear. "But Mrs. Williams," I said, "he can't talk. He isn't responding and we haven't been able to wake him up." "Doesn't matter," Mrs. Williams said. "He just needs to listen. And after he does, whether he's asleep or awake, he'd best do what I say." I began to see the force of the Williams family rule. I held the phone next to her husband's ear. "James?" Mrs. Williams said, "Do you know who this is? This is Nettie, and I am not happy with what the doctor is telling me. You don't just lay down and stop trying! Here I am on my own and you don't see me giving up! Make an effort!" Mr. Williams lay silent and still, his face unchanged. When I reclaimed the phone, Mrs. Williams told me, "It may take a little bit of doing, but I am not done with that man yet. He will come around." "I hope you're right, but his body is very stressed, very weak. I'm sorry. His condition is critical; he could go any time." "Yes, honey, I understand. Lately doesn't seem like either his body or his brain wants to keep trying. But my James is a man of spirit. He loves people. He was a great preacher, back in the day, but he's not ready for the Streets of Gold just yet. You call me again tomorrow. Let's see what we can do together to get that old man back for a while." The next afternoon, I again called Mrs. Williams and held the phone to my patient's ear. "James? Do you know who this is, James?" I was stunned to hear Mr. Williams mumble something. "That's right, it's Nettie. Seems like you're just lollygagging over there. You show some gumption, now, you hear?" Mr. Williams moved his mouth again, inaudible. He seemed to be trying to reply. When I took the phone from his ear, his eyes opened—briefly. "Mrs. Williams," I said, trying to sound professional despite my excitement, "he opened his eyes." "Oh, honey! James knows better than to mess with me. Whatever needs doing, we can get done." On the third afternoon, Mr. Williams was awake when I walked into his room. I'd never seen him conscious, and I was surprised by his transformation. I asked him where he was, what year it was—all the usual questions. He whispered answers—wrong answers, but still—to every question. He couldn't swallow. He couldn't focus his attention. But he was no longer absent. Mrs. Williams, hearing my good news, seemed oddly serene, as if she'd never imagined anything different. "He's doing good," she agreed, "but he still has a long road to walk. James? Do you know who this is?" "Nettie," the old man whispered. "Nettie." "Yes, it most certainly is. Are you still lying up in that bed? How long is that gonna go on?" Mr. Williams looked abashed. The fourth afternoon, he raised his head off the pillow when he saw me holding the phone. He grinned feebly. "It's Nettie," he said. His voice was stronger; he was alert, engaged. He peered at the phone as if trying to see his wife through it. Her scolding was easy to hear. "Is it right, what I been hearing? You're off your feed. That is not acceptable. You listen here, James Williams. You are going to eat. You hear?" He nodded. He smiled. So did I. The next morning, Mr. Williams passed his bedside swallow evaluation, and his lunch tray was half-empty when I came for our chat. He grinned when I came in. "Call Nettie?" he asked eagerly. When I handed him the phone, he beamed. "James? Do you know who this is?" "Nettie! My Nettie!" I watched his animated face as he answered "Uh-huh" and "I will" to each instruction from Mrs. Williams. At the end of the call, I heard Mrs. Williams say, "You need to thank that doctor, James. She's been putting in a lot of work trying to get you better." As I took the phone from his hand, Mr. Williams began to cry, silently. Then he raised his arms, stretching them toward me. "You," he said, catching his breath. "You saved me. Thank you." He stretched his arms further, and I understood that he wanted a hug. "You and Nettie, Mr. Williams. You did it all," I told him, embracing his frail body carefully. The next day his labs looked much better; the day after that they were better still. He finished the course of antibiotics and looked stronger every time I saw him. Nettie's voice, it seemed, had infused him with strength and energy. True, his memory was not reliable, but he was always delighted to be reminded of what he had forgotten. He insisted on a daily hug, yellow protective gown and face shield and all, even though all the protective gear conveyed little warmth. On the day that he was discharged, though, I could feel him gently hugging me back. "Nettie says I'm back to a strong man now," he told me. "I'm gonna go home to Nettie." It was hard to tell him that he wouldn't be going home, and that there was a sickness that made it dangerous for him and Nettie to be in the same room. I was afraid he would be devastated, but he patted my hand. "That's all right," he said, comforting me. "I will see Nettie after it's gone." I was glad to have the chance to speak with Mrs. Williams one last time, just before her husband was discharged to his assisted living facility. She laughed when I told her that she was a miracle worker. "I guess miracles come in a whole lot of different packages, doctor. We did good together." Nettie transformed me a bit, too. I'd never thought of patients as just cases. What I was neglecting to do, though, was to see the patient's out-of-hospital identity. Do you know who this is? is the question I now ask myself about every patient. Records, histories, and lab results add up to information, but not to insight; and certainly not to wisdom. Based on an abundance of data, a diagnosis could be made and a course of treatment prescribed. When work hours are long and hectic while patients are many and urgency relentless, it is easy to succumb to generalizations. I would not have guessed that any patient would respond so powerfully to a spouse's "telemedicine." The intravenous antibiotics, the hydration, and the attentive professional care were all essential to treat Mr. Williams' sepsis. The powerful impact Mrs. Williams had on her husband's improvement, though, cannot be quantified. Her impact on me was perhaps just as strong. As I hurry from one bedside to the next, it is her remembered voice that prompts me to keep asking, Do you know who this is?