Hatpins

Irene Koplinka-Loehr

doi:10.1370/afm.2135

Abstract

Hatpins is a first-person narrative that delves into a physician’s experience of a patient death during the early years of residency. The essay reflects on the conflicted physician-patient relationships that can develop even over the short tenure of residency. While residency seeks to create medically prepared and compassionate physicians, this piece speaks to the importance of the often subtle learning that comes from ethical, social, and cultural aspects of both the lives and deaths of our patients.

Hatpins? You ask me where to find them and I think: I know nothing about how to find these things here. I’m just a resident passing through; they train us in hypertension and diabetes management, not hatpin location. You, you are the one who has lived in that apartment for 40 years, lived after a fractured marriage with too-nosey neighbors. Lived next to hollow memories filled with echoes of estranged children. You, who drank herself into isolation and, alone, pulled herself into sobriety. You ask me and I shrug, thinking, “What would one need with a hatpin?”

That night I find myself searching online and 12 stainless steel hatpins arrive in the mail. I present them to you at our next appointment. You nod, knowingly. “Oh, hatpins. Thank you.” I place them under the seat of your walker and hold the door open as, hunched, you wheel outward. Two weeks later a felt hat with a solitary flower is secured firmly over thinning gray strands.

I found your son on the Internet after our first visit. Two clicks, one powerful search engine later, and he was smiling back at me. One phone call and he could have been accessible to you. But I never told you he was local, I never mentioned how close he was—the CEO of a corporate firm four blocks down the street. You told me that you never wanted to speak to him again—“How could he fall in love with another man?”—and closed the conversation, suddenly muttering about how “Hispanics” expect to have it all in this country, when you came with nothing; a 19-year-old German-speaking newlywed with a baby on the way.

It is a month later when I see you, hospitalized now, slowly inching your legs to the edge of the bed. I hardly recognize you in a gown, fluid overloaded, face waxy. You acknowledge my presence, and scant moments pass before you shoo me out as you wheel stiffly toward the commode. Perhaps you hope to not show me your deconditioned self—this further-slowed version of you. Or perhaps you knew the valve replacement surgery would be your last, that your earlier statements of “I’ll live until 100” were not to be. Or perhaps you saw this as a final betrayal: you in the hospital one last time, heart failure unmanaged on the medication to which we held so tightly. Working over nights, I did not visit you after the surgery. I thought of you, I followed your chart, I worried, but I did not visit, instead leaving on my own vacation.

The e-mail arrived while I was away. The subject line “patient deceased,” heralding what I already knew. Tears coursed, reading and rereading the report of your terminal discharge. “Patient has no next of kin, friends, or emergency contacts listed. She has no living will or health care proxy. Ethics was consulted for determination of DNR status.” Insensitive, bigoted, and yet fiercely persistent, prototypically stoic; the ripples of your life lapped into mine. A lifetime of quiet struggle giving way to burgeoning silence. Never again would I see your shuffling gait, your anhedonic visage, your blunted enthusiasm for me.

The guilt still lays heavy in my stomach—guilt from not preparing you for this end, of not discussing all treatment possibilities, of your avoidance of your death and my lack of insistence to address the possibility, of my not visiting you—alone in the ICU in your last days.

I see you in my patients with substance abuse and depression, I see you in the missed connections between partners, or mothers and children, I see you when I push myself to reach toward a patient rather than push away. Somedays, when I walk into the clinic I catch, swinging my head around, thinking it’s your stooped form at the edge of my vision.

“No next of kin, no emergency contact, no proxy. Time of death 0328.” You thought you would live forever. And in some small way I believed you.