The young resident presented the patient in the usual dry terms we use for such things.
"The patient is a 42 year old woman recently hospitalized for cirrhosis due to alcohol use. Her cirrhosis has been complicated by esophageal varices, encephalopathy, and refractory ascites."
In other words, the woman has drunk herself nearly to death.
"Is she still drinking?" I asked.
"She says not. She says she stopped about six months ago when she first got sick."
"What did GI say? Did they refer her for transplant evaluation?"
"No," she said, a bit disappointedly, "they said she wasn't a candidate."
I pulled up the GI consult in the computer:
In summary, Mrs. Polascyki is a 42 year old alcoholic with end-stage liver disease and unclear duration of sobriety. Given her severity of illness, lack of a permanent residence, and recent drinking, she is unlikely to survive long enough to qualify for transplant.
"What do you think?" I asked her.
"They said she's not a candidate."
"I know. I read it. What do you think?"
"She's stopped drinking. She wants to get better. She's shown up for two appointments in a row. She's trying."
"OK, finish up her paperwork for this visit. Let me make a quick call."
I paged one of the GI fellows. She had been both a student and resident of mine in the past and I knew she had a good head and a good heart. I ran the case by her.
"Why didn't they refer her for transplant eval?" she asked me.
"Why do you think? What can we do next?"
"Ask the secretary to overbook her with me next week. I'll get the workup going and make the calls."
We sat there afterward, the resident and I, her pained look fading.
"You know," I said, "she's probably going to die before she gets a liver." Her eyes teared up a little.
"But she's trying," she said, not quite sure if it was a question or not.
"Yes, but just as important, you're trying. You're giving her hope. Whether she lives or dies matters, of course, but either way, for maybe the first time ever, someone cares enough to go to bat for her. She sees that, you know."
The young doctor nodded.
"Whatever else happens, today was the day someone believed her and tried to help her. If she doesn't make it, she's going to die knowing someone cared. That matters."
At the beginning of the year, I tell my residents that I understand their outpatient clinics are challenging. "It's service," I tell them. "We're taking care of people who have nowhere else to go. No one wants them."
I was wrong.