L'Shanah Tovah (draft title was: Punched in the Gut)

Earlier this week; beautiful, bright sunny morning in the office; listening to the messages on the machine.

A cancellation; a refill; then,"This is the ER calling to let you know your patient GF was brought in dead on arrival this morning."

Suddenly I find it hard to breathe; did the sweet, cool morning air just become thicker? Did a cloud move over the sun, or is it my eyes abruptly filling with tears?

First thought: What the hell happened?

He was only 45, diabetic for about six years, but under good control with insulin and orals. He was also on a pile of psych meds for some kind of schizophreniform diagnosis, and he drank -- though he only admitted it to me off and on. His latest meds were Lyrica for neuropathy, recently added to Neurontin (planning to taper.) So it could have been anything from a massive silent MI to respiratory arrest from the potentiation of alcohol and CNS depressants.

Second thought (fleeting): Did I screw up? Miss something? Do something? Not do something?

Check the chart. Last visit in August with an A1C of 7.1. Only notes since then are letters from the neurologist about meds. Clean conscience there.

Third thought: Sadness

Now the tears threaten to well over. He was a little odd, but he always shook my hand firmly at each visit, both on coming and going. Looked me straight in the eye despite his flattened affect. Never failed to offer an appropriate greeting for whichever Jewish holiday was approaching. Often brought me Mishloach Manot (food gifts) at Purim. Apologized whenever he called on a Saturday for disturbing me on Shabbes (not "Shabbat"; "Shabbes" -- emphasis on the first syllable.) He may have been a time consuming "difficult" patient off and on through the sixteen years we knew each other (back when I still admitted to the hospital, he came in regularly with pancreatitis) but in spite of his limitations he was a good man. A friend as well as a patient, and I know I will miss him very much. Out the window I look differently at the sun, knowing now that it shines on a world without GF.

Final thought: Is this beautiful day his way of letting us know he's ok?

Postscript: I had three calls in to the coroner's office trying to get more information, but Mr. F, the patient's father, calls me first. I know him well; he takes care of G's prescriptions for him and gives him his insulin shots. We've met in the office many times.

I tell him how sorry I am. He speaks in a soft, high-pitched voice; very precise, with a Yiddish-like accent. He thanks me and asks if I've heard anything more. I haven't, but he has: the coroner's office has told him that they found a lung abscess at autopsy. GF died of sepsis.

What the hell? (Later in the day I did get to talk to the coroner, a pulmonologist and old friend. Lung abscesses can indeed be totally asymptomatic; until they break through into the bloodstream and produce septic shock and death. Still weird, but I suppose it's worth knowing that it wasn't an MI or something else.)

I tell the father I'll try to get a copy of the autopsy report when it's done and let him know if there's anything else; answer any questions he and his family may have. He thanks me.

He tells me the service will be today at 3:00, graveside. He begins talking about how much he is going to miss his son. Despite his psychiatric issues, they were close. He had recently talked G into coming with him to the gym. His voice begins to waver.

Then, in the middle of telling me of his shock and pouring out his grief in the wake of this unbearably sudden and unexpected loss, his voice steadies, as if he's just remembered something very important. He says to me, "Oh, and Dr. D; I'd just like to wish you a Shanah Tovah, a healthy and happy New Year to you and your family."

I didn't bother trying to stop the tears as I thanked him and returned the greeting.

(Rosh Hashanah, the Jewish New Year 5767, begins at sundown tonight.)