LAUSR

I have limped through the first few months of residency. It's my vacation week, and I'm sick. I'm cycling through the stages of grief, passing quickly by denial because I'm painfully congested and moving on to anger and even jealousy at the relatively glamorous life Andrew, my partnerwho is not in medicineleads. When I say glamorous, I mean that he often has 2-day weekends, whereas I spend most of my Saturdays writing discharge summaries and repleting potassium. You never get sick, I pout. Well, I'm always sick. Which is actually true, but I often forget it. Andrew carries all the weight when we backpack so I can frolic freely. He shimmies up rockfaces and sets anchors for me so I can drag myself up with a rope. He rides his bike with no hands. He even does that somersault thing in the pool when swimming laps. In my mind, I still have the fresh picture of him sprinting through the rain on a cobblestone street in Mexico while carrying both of our suitcases and flagging down a local bus. Using his fluent Spanish, of course. What a dreamboat. It's also possible that he will lose all of those abilities. Andrew has primary sclerosing cholangitisa chronic, progressive illness in which the bile ducts fibrose and scar down, typically causing liver failure. In his bathroom drawer, next to the beard brush I wish he actually used, is a multicolored medication organizer that he has to use. Andrew's liver will fail. It used to be hard for me to say that because part of me didn't believe it and part of me was too scared to accept it. Nowhere in my description of an ideal partner is chronic illness requiring massive organ transplantation. Until I started my internal medicine residency, Andrew's fate was actually relatively easy for me to ignore. Suddenly I went from backpacking through Europe with my soulmate to feeling pummeled by case after case of illness stripping people of the lives they had planned on living. Suddenly I was responsible for hospital admissions and discharges, although I often felt powerless to change much about most people's overall prognosis. Shellshocked by this new blend of responsibility and powerlessness, my mind would often turn to the unstoppable progression of Andrew's sclerosing cholangitis, his goddamn bile ducts fibrosing for reasons we cannot control and don't even fully understand. I oscillated between different coping mechanisms. One day I would quite literally attach myself to Andrew, holding his hand even as he was trying to shop for groceries; the next, I would become distant and inappropriately annoyed at him for losing his keys. We argued, and sometimes I wondered whether it was worth working through our differences when so many of his finest attributes might fall away. We had been together about 2 years; too long for me to help myself from constructing various permutations of our future and too short for any illusion of permanence. The calculus felt too abstract and, frankly, too overwhelming. Then came my rotation on the liver transplant unit. One of the posttransplant patients had a code blue during one of my first mornings before rounds. His heart had stopped beating; I did the most vigorous round of chest compressions of my life before he was pronounced dead. Minutes later, we went right back to talking about the rest of the patients on the service. My throat felt like sandpaper. I had to stop myself from simply walking out. Methodically reporting liver function tests in that moment felt like punishment, but I didn't cry. There was still some distance. I still couldn't quite imagine Andrew being in an ICU bed with so many tubes and lines. A week or so later we admitted a patient with liver disease awaiting a transplant. I'll call him Mr. Roberts. Mr. Roberts came in with hepatic encephalopathy; he was confused from his liver failure. He had been a swimmer in high school, like Andrew, so he knew how to do the somersault thing when changing direction in the pool. However, because he was confused, he had forgotten to do the somersault thing and smashed his face into the concrete, bringing him to the hospital. His very high MELD score meant that he had a good chance at receiving a transplant during his admission. His confusion improved when he began receiving medication, and I would often see him and his wife walking laps around the hospital floor in the afternoons. Each morning when I prerounded on him, he would make small talk, alerting me about the weather forecast or the latest front-page news. And his wife was always there, stretched out on a cot next to his hospital bed, offering a tired smile. I liked him. I liked them both. The day he got a liver, the three of us were elated. Sure enough, Mr. Roberts had a new liver when I next saw him. He was also floridly psychotic. I've done my fair share of talking people down from bad acid trips; that was nothing compared to Mr. Roberts' psychosis from his steroids. The liver transplant specialists started referring to him as Roberts A and Roberts B. Roberts A was hyperactive, paranoid, and convinced that aliens had infiltrated the soft tissues of his body. Roberts B was also psychotic but just continuously muttered, Quiet Jesus, quiet Jesus, quiet Jesus, quiet Jesus. Days passed before we could balance his essential antirejection medications and control his psychosis. Every day his wife had deeper and darker circles under her eyes. One morning I asked her how she was holding up. Tears welled in her eyes as she told me, I'm just hoping for Quiet Jesus' today. She kissed his forehead and stroked his hair. I left the room, and the tears poured hot down my cheeks. That night, I was distant with Andrew. I didn't like the dinner he had made, and I said so. Then I felt guilty. He could tell that I was feeling sad and translating it into generalized grumpiness. He asked me whether I wanted to talk about it, and I said, No, I just want to feel sad. Okay, he said and sat a little closer to me. He intertwined his fingers in mine. Andrew has so many talents that have made me swoon. He can pitch a tent in about 20 seconds, he can assemble a bike and ride it through Europe he even ferments things. The impermanence of these abilities socks me in the stomach every time I see a sick patient with liver disease. My relationship with Andrew has plunged me into a different side of doctoring where the patient isn't so different from my partner, more same than other. It has pulled my heart more deeply into my work as a physician. Andrew helps me take deeper breaths. He never tries to change my feelings but always helps me discover new perspectives. He loves me through my worst moments and guides me toward my best ones. Sitting next to him in that moment, the dreamy stuff didn't matter much to me. And impermanence felt okay. He kissed my forehead and stroked my hair. I've never loved him more. Audio. Michael A. Lacombe, MD,AnnalsAssociate Editor, reads The Liver Transplant Unit by Elizabeth Adler, MD