By Tim Lahey

Two days ago, Jimmy stuck a used needle into the soft skin of his forearm, and released 20 milligrams of black tar heroin and a bolus of bacteria into his blood.

The bacteria floated from vein to artery as he nodded, eventually sticking themselves to the ragged edge of his aortic valve.  There they multiplied and burrowed until each systole whipped a two-centimeters of snot back and forth in his atrium.

Fevers came first, which Jimmy ignored while buying more black tar at a rest stop on I-91.  A day later, little red stigmata appeared on the palms of his hands as plugs of snot lodged in small vessels there.

When he couldn’t breathe, Jimmy went to the ER.  My medical student and I met him there as he shook in bed.  A snarl of IV lines snaked under the covers.

Jimmy gave one-word answers to my questions, and did not open his eyes…

Jimmy’s mother cries in the corner. She holds her hands up and open, the way you might receive a baby.  Or, the way you indicate helplessness when your baby is now addicted to heroin and shivering in a hospital bed.

Jimmy’s heart is failing.  Antibiotics alone will fail him.  Soon a surgeon will open Jimmy’s chest, cut out his heart valve, and sew in a new one.  I say this as gently as I can.

I also feel Jimmy’s pulse, and listen to his heart.  I move the stethoscope over each of the valves of his heart. Pulmonic.  Aortic.  Tricuspid.  Mitral.

“See if you can hear it,” I say, and I look at the third-year medical student.  Jimmy opens his eyes.

The student steps forward with a start.  Silent until now, she puts her hand on Jimmy’s shoulder, too, and she gives him a tight smile.

She listens, moving her stethoscope from location to location.  This may be the first sick heart she has heard.

She is careful.  She has been reading.  But I know what she hears: nonsense.  Until you hear a thousand hearts, none of them says anything.

I say, “You know how your heart goes ‘lub dub?’”

She nods.

“Or, really, it sounds like” – I make the sounds with my lips – “fump fummp.”

“See if you can hear it like this instead,” I say, and I mimic the murmur I hear in Jimmy’s heart.

“Fump sheew fummp,” I say, adding in the sound of his murmur.  “Fump sheew fummp.”

She listens.  She squints.  Maybe she hears it.  Maybe she doesn’t.  She starts to nod.  She looks up.

“Now see if you can hear the second part,” I say.  “Fump sheew fummp –” and then I whisper: “(shump).  There is a quiet second murmur in there too, right at the end, just barely.  Hear it?”

She listens.

I put my stethoscope away, and finish the exam.  I push on his stomach.  I feel for a spleen.  Softly turning his hands over in mine,  I look at his skin.  I examine his knees, and his feet.  I take my time.  I hope the student learns from this too.  I am a detective.  I am a healer.

I ask if Jimmy has questions.

“No,” he says, eyes closed.

“Ma’am?” I say, looking at his mom.  She shakes her head.  There is a tear on her right cheek.

I start to leave, and Jimmy sits up abruptly.  “Doc!”

I see he is missing a tooth when he says his one complete sentence.

“I don’t want to die,” he says.

Fump.  I wait for something to say.  Sentences suggest themselves.  Reassurances.  Probabilities.  Hope.  None are right.

I look at the medical student.  I am a confessor.  I am a listener.  I wait.

“I don’t want you to die either Jimmy,”  I say.

When we leave the room I ask the student, “So what did you learn?”

Tim Lahey, MD MMSc, is a physician and ethicist at Dartmouth-Hitchcock Medical Center and Dartmouth’s Geisel School of Medicine. He is Director of Education at The Dartmouth Institute for Health Policy & Clinical Practice, and a Public Voices Fellow at Dartmouth College.