A Celestial Discharge
by Mike Litrel, M.D.

Curled up in a fetal position and too weak to answer my knock, he nodded when I introduced myself. His mouth was parched, and his voice was too soft to hear, and his eyes almost empty of life.

I sat by his bedside and read his chart. It was a telephone book of illness and suffering. His most recent problem was a herpes lesion on his backside, for which he was on intravenous antiviral medication, in addition to the multiple medications that were part of the AIDS cocktail. Reluctantly he agreed to let me see it.

He gasped in pain as I tried to open his diaper. Very slowly I pulled it back. He wept dry tears in his agony, his body shaking. I held his dry bony hand in mine. His long yellowed fingernails dug weakly in my palm, and I squeezed back in a futile effort to provide comfort.

My jaw dropped in surprise at what I saw. A sore larger than a record album covered his entire backside. Bright red with a white border, it resembled a giant cold sore - but it covered 20% of his body.

The day I had started internship, dressed in my new white jacket embroidered with my name on the pocket, I had stared at myself proudly in the mirror, convinced I was going to be the best doctor there ever was. In the months afterward, I had strived always for the highest degree of professionalism - how best to present myself to my patients, the nurses, and other doctors so I was worthy of their admiration.

I was full of myself.

But staring at that man's bottom, all my aspirations of being professional crumbled. I had no idea what to say to this human being. I had no idea what to do. His physical agony was beyond reason.

And he was abandoned. Not a single human being had visited him during his entire stay. He had contracted a disease through sexual relations or intravenous drug abuse, and now he was all alone. Part of me wished that he somehow deserved it, that maybe it was a just punishment for his life style. It would make me feel better. But as I stared at his ulcer for a long while, I knew for certain no one deserved what he was enduring. I wanted to be a good doctor and help this man. But my mind was blank.

Finally I heard myself speak. "I am so sorry... I have no idea what to do for you... No one should suffer as much as you are." I felt his hand weakly squeeze mine. I was surprised to see a look of gratitude in his eyes. I had to lean down close to hear what he said next.

He was asking for pain medication. Of course, I assured him. Back at the nurse's station, I read through his medication list. No pain medications had been ordered during his entire hospitalization, by any of the exhausted residents rotating through. I was infuriated. At least we could help his pain! But his nurse shrugged her shoulders. He'd never asked for anything, she told me apathetically.

I wrote for morphine and hovered over the nurse to make sure the medicine was pulled. I reassured my patient I would see him first thing in the morning. I was not going to neglect him like the previous intern had.

He died in the night. And when I found out the next morning I was grateful.

That was more than a decade ago, and since that time tens of thousands of patients have come under my care. But in my mind's eye, I still see this patient clearly, feel his bony fingers with nails like claws in the palm of my hand. Nagging feelings percolate among the memories, and I fight away guilt about the timing of his death. For the hundredth time I ask the questions - Why did he linger so long? And why, under my care, did he die?

And at last, the other day, an answer unfolds in my thoughts.

Maybe he had just been waiting for a friend.

Three painful months of my twelve month internship in Obstetrics and Gynecology were spent on the General Medicine Wards at Grady Memorial Hospital. Even the Internal Medicine residents - who actually belonged there - hated working the Grady Wards. The hours were long, the patients were sick, and it was a chronic frustration trying to get anything done within the hospital bureaucracy. The typical OB/GYN resident, taken away from Labor and Delivery and the O.R., hated it even more. I was pretty typical.

So I couldn't help but sulk as I received a sign-out from the Internal Medicine intern whose patients I was taking over. He handed me a stack of cards, each detailing a patient's history and their clinical course. As he approached the bottom of the deck, his smile grew bigger and bigger, threatening to explode off of his face. His Grady month was over. Hurray! Hurray! Hurray!

I felt like punching him in the nose.

The last patient signed out to me was a man in his mid-thirties dying from AIDS. His history was detailed on three separate cards, each written in the hand of a different doctor. The man was a "rock," the intern remarked. "Rock" was Grady vernacular for a patient you couldn't get off your service. His medical problems were too chronic for him to get better, and too serious for him to be discharged. The Grady Wards were full of rocks. They ate up your time, and emptied you of hope.

I was the fourth doctor assigned to this man's care. For more than two months, the intern explained, they had been waiting for his "celestial discharge" - medical slang for death. I hadn't heard the expression since I'd first been on the Wards as a third year medical student. The intern under whom I had worked at the time was a particularly charismatic person, who camouflaged his compassion with a macabre sense of humor. Whenever a difficult "rock" died, he would slowly kiss his first two fingers and ceremoniously lay them on the patient's card. "The Kiss of Death," he'd solemnly announce. Then he'd rip up the card, toss the pieces into the garbage, and cheerfully declare, "Another celestial discharge!"

His antics were unprofessional. But it hurts, taking care of dying people. And sometimes his humor was sadly needed.

Still, I didn't relish the idea of becoming a jaded intern with a well-developed sense of humor. Clutching the stack of worn cards that represented my new patients, I made my way around the Wards, saving the AIDS patient for last. As an intern simply passing through for a month, I wondered what I could possibly do for him - and how I would get around his nurses.

Most of the nurses at Grady Hospital were more than adequate, some simply superb. Nurses tend to be the kindest and most compassionate people you will ever meet.

But still, a seasoned Grady ward nurse with decades of experience in the trenches is not about to take orders from an intern still wet behind the ears. So I wasn't surprised when his nurse refused to locate the patient's chart. Not being one of the more compassionate ones, she said simply that she was "busy." And besides, her fingernail polish hadn't dried yet.

I found the chart on my own and saw the patient. He looked like a concentration camp victim, emaciated beyond reason.