Blankets of Reassurance

Lung sounds can be funny when you are a medical student. There you are in the exam room, auscultating the patient’s back silently as he breathes deeply in and out. You try your hardest to discern any notable pathology present in the lung parenchyma, but ultimately lack of experience in listening to these breath sounds leaves you unsure whether what you heard is normal or not. Sometimes it feels like you are pretending—briskly going through the motions of the physical exam, knowing the attending will step in right behind you and mimic these exact maneuvers to verify your findings. This is the medical student’s security blanket, and I am thankful for its warmth.

While the blanket is always there when you need it, I distinctly remember one time during my family medicine clerkship when I knew I did not need its reliable security. It was the second patient of the day and I was fresh off a straightforward annual exam, eager to move onto the next room. After a brisk knock, I swung open the door with gusto, energized after the pleasant interaction I had just experienced in the neighboring exam room. There on the bed sat a sickly appearing Hispanic male, slightly shorter than myself but about 100 pounds lighter. He looked fragile, with both hands placed on his knees while his body actively shook with chills. His eyes were wide open, the pupils were running out of space to dilate any further, and he began to cough shortly after saying hello to me. Without greeting the patient, shaking hands, or even thinking, I quickly sat down in the exam room chair and slouched forward toward the patient. It was my body’s own response to the suffering of the other body in the room.

We began the interview, gathering bits and pieces of the story in between episodes of hacking and sniffles. The patient informed me that he had smoked meth several hours before coming in to clinic. For the past couple weeks it was the only way he had the energy he needed to work at his construction job. We went through a full history, addressing all symptoms, health history, sexual history, family history, and everything in between. It came time for the physical exam and I arose from my chair wrapped in my security blanket, ready to auscultate the lungs. With the stethoscope placed firmly on the patient’s back, I asked him to take a deep breath in and out.

Whether they were rhonchi, crackles, wheezes, or all of the above, did not matter—I knew something was inherently wrong. As the patient inspired and expired, it was as if the lungs were screaming out for help, drowning in a pool of their own secretions. The room became stuffy; I felt like the congestion in the lungs began to take over the entire examination area. Reaching over to the computer mouse with armpit sweat exposed, I pulled up the patient’s lab results. His total white blood cell count read 84, an alarmingly low number as I vaguely recalled the normal range to be somewhere over 4,000—I would need my security blanket to confirm. Every last white blood cell in his body was in a standoff against this pulmonary monster that had been screaming at me on the other end of the stethoscope. The patient’s chills suddenly transferred to my body when I began to realize the etiology underlying this man’s sickly appearance. I was in no condition to tell him what I thought, nor did I even know how—no amount of medical school training can fully prepare you for that delivery. After a brief moment of reassurance to the patient that we would do everything we could to help him, I slowly trudged down the corridor to find my attending. The patient was later diagnosed with AIDS after an HIV screening test was performed. That pulmonary monster was later termed pneumonia.

My attending greeted me when I stepped out of the patient’s room. Just as the patient’s lungs were drowning in a pool of fluids, I was drowning in a pool of my own emotions. Realizing this man now carried a diagnosis that would affect him for the rest of his life, it felt inhumane to present the case to my attending in the clinic hallway. It felt inhumane to present information about this patient at all. I did not know what to feel at the time. As medical students, we take pride in answering multiple-choice questions and getting the question right when we “make” the correct diagnosis. This time I was angry.

Hearing a disease in this way for the first time changed me. The brief sounds on the other end of my stethoscope gave me a new respect for how patients manage to cope with such crippling illnesses. It gave me perspective on how our bodies fight back against foreign invaders. As a young medical student, I acknowledge my need for reassurance when providing medical care to a patient. But just as I need reassurance, the patient undoubtedly needs it as well. While the security blanket may not help me identify lung sounds on auscultation, it does encourage me to give support and reassurance to the patient as they face adversity. Perhaps I am not the only person in the room who needs a security blanket, and it is my job as an evolving medical student to take off that blanket of reassurance and share it with the patient in times of need.