2024 3rd Place GHHS Essay Contest Winner
Scott Nishioka, MS3
“Mr. L is a 50-year-old man with a past medical history significant for heart failure with reduced ejection fraction, ischemic stroke, hypertension, hyperlipidemia, and methamphetamine use...” There it is, I think as I present this new patient to the team. It’s a story all too familiar to healthcare providers – familiar enough to make anyone numb to its connotations, its assumptions, its subconscious implications. Methamphetamine use. Heart failure. Stroke. Maybe infective endocarditis, but otherwise with a laundry list of other co-morbidities to match. Admitted for acute exacerbation of heart failure with acute hypoxic respiratory failure. “If only he’d stop smoking meth” – the initial thought hangs heavily overhead, with such humidity that one could almost whisk it straight from the air. If only addiction were that simple.
We walk into the patient’s room to find him slumped in bed - his eyes closed, shoulders shrugging with every labored breath. Nasal cannula snaking around his neck, hissing with a continuous flow of oxygen. One look at his legs will tell you what the problem is – lungs drowning in itself, kidneys clenching with under-perfusion, and his heart barely able to keep up. A shell of his former self. And yet – I realize as the team conducts their full physical exam – I haven’t caught him once without his all-black, hole-worn, sweat-encrusted Anaheim Angels cap on. Even in his current state, he can’t help but to remark on the Angels’ terrible season. Another season missing the playoffs despite boasting two of the greatest baseball players on Earth. “So junk,” he says. He can only just get the words out between breaths. If anything, you have to respect his commitment.
Over the course of his hospitalization, I get more and more opportunities to talk story and baseball with him. It becomes clear that Mr. L is immensely proud of who he is and where he comes from – mistakes and all. He admits that he has a long history of meth use dating back to his early twenties. Since then, he’s been labeled a hundred different things – drug addict, non-compliant, bad patient, bad brother, etc., ad infinitum. But beneath all those labels, he’s a local boy from the Windward side of Oahu. A local boy whose life once revolved around baseball – a passion that he genuinely excelled at. He even made the high school varsity team as a freshman and had dreams of playing college ball, or beyond. “Brah, gimme anybody in the state of Hawaii. I could whack ‘em all, y’know. Even my braddah will tell you dat.”
Unfortunately, such dreams never came to fruition due to financial circumstances. Things became especially difficult for Mr. L after his father died, which he states was the inciting moment of grief that would propel him toward a lifetime of methamphetamine use. After years in the downward cycle of unemployment, houselessness, and irrevocably strained relationships, Mr. L had nowhere else to turn except the streets and beaches of Waikiki.
These days are far more hopeful. He has stable group housing, has a great relationship with his brother, and is beloved by his housemates – many of whom are disabled and depend on him to cook their meals. These days, his cooking and, more importantly, his ability to care for others are what he takes most pride in. He is loyal to them and their needs, even at his own expense. Throughout the hospitalization, his symptoms steadily improve. However, not without the help of Milrinone, as repeated attempts to discontinue only result in worsening of his condition. Because of this, it would technically be impossible to safely discharge him. And yet, all he can discuss is when he’ll be discharged, such that he may resume his caretaking duties back home. Each day, a careful negotiation to convince him that the best way to care for others is to maximize his own health before his return. Each day, he eventually concedes. Just like with the Angels, you have to admire his relentless commitment.
One final afternoon, we find Mr. L fully dressed and pacing laps around the Cardiac Intensive Care Unit. He is anxious to leave despite our advice, filled with concern for his friends. One peek into his room reveals that he has already packed. It’s clear: he has had enough and can no longer delay his obligations. “I cannot stay here, waiting around. I get choke plenty people for take care of. I promise I strong, you know. I can handle. These people depend on me.” He looks me dead in the eyes, resolute in his decision. Our only option left is to optimize his medications outpatient and to trust him.
Reflecting on such an experience, I am reminded of the beauty that defines medicine in all its glorious imperfection. Yes, the outcome was less than ideal. However, by centering Mr. L’s values, I believe that we actually bought him more time to do what is truly important to him – to care and to cook for others. And no matter how fragile, miniscule, or transient that positive outcome may be, it matters.
It is a privilege to discover what truly drives someone; to peer gently behind the curtains of their actions and glimpse at their heart’s inner mechanics. Not in its physical pumping via nerve impulses, muscle contractions and pressure differentials, but with the passions and relationships that motivate us most to action – even when it comes at significant self-expense. Medicine provides the unique opportunity to do so, where we often observe patients at their most vulnerable. It is only through this vulnerability that we may reach for true understanding with one another. In turn, I am eternally grateful to Mr. L for arming me with the perspective that, even amongst the chaos of medicine, we can still embrace the moment to pause and truly look at our patients – including, or perhaps especially, the “difficult” ones.
