Wednesday, August 31, 2011

Sometimes We Are Doctors

If death was the end zone, George had been on the one yard line twice in the last five years. And I, as part of his team of doctors, watched as he stubbornly maintained his goal line stand. Miracles rarely happen in medicine. They certainly don't happen to the same person more then once.

Yesterday as George glided into my office you would have never known that eternity's grip had been so close. He was the picture of health. Strong and confident. He walked with a lightness found only in those who have escaped the ICU's tenacious grasp.

His complaints were minor. An ache hear...a pain there. Nothing extraordinary. Our conversation eventually turned social. After leaving the office he was going to his rental property to mow the lawn. It was a house. He owned it for years.

His current tenet, Jim, had moved in shortly after George's first hospital adventure. A young man with two children. Originally his wife had lived with them but she left Jim and the children one quiet morning.

Jim, overtaken by depression, eventually lost his job.

There he was. Two children. No wife. No income. Living in a rental property with no hope of having money to pay the next months rent.

George clearly remembers the day sitting in his kitchen with his hand on Jim's shoulder as the kids slept quietly in their bedrooms. Don't worry about the rent. You'll pay it when you're able.

After all that George had been through...compassion was more a privilege than a burden. He would wait. Two years to be exact. Until Jim could cover the monthly costs. Another year before he would pay the past dues. But Jim's children would grow up healthy and happy.

Looking across the exam table into George's warm kind eyes I felt great pride at being one of his doctors. One of the team of people who helped him stave off the inevitable. Because George would then help Jim. And Jim would bring up two wonderful children. And Jim's children would go on to touch other lives. Like dominoes my good intentions had helped start a reaction.

I believe George sensed what I was thinking. As left the office he turned and looked at me squarely.

We are all patients sometimes...

and sometimes we are doctors.

Sunday, August 28, 2011

I Am All Of These

The edges of Cameron's lips rise undeniably toward the clear blue sky. His legs move methodically. One motionless on the scooter and the other periodically kicking to propel himself forward. He weaves in and out dodging my shadow as I jog beside him.

I struggle to keep pace. My breathing unsteady and labored. My joints aching. And my brain foggy from lack of sleep and replaying the events of the day.


The hospital was uncharacteristically quiet. Even for 5 am. My eyes fluttered with fatigue as I willed my mind to focus after two nights of countless interruptions. I felt no joy in this early morning excursion.

The room was lit by a small lamp. A woman in her forties sat with a young child curled on her lap. A boy...Cameron's age. My eyes adjusted to the absence of light.

The middle aged man lying on the bed looked far older then reality. He took deep irregular breaths. Each pause a question. His wife held his hand gingerly. I inhaled the seen cautiously. I couldn't help but think of my dad. Were his last moments like this?

The woman dabbed her eyes with a tissue. She tried to move slowly to avoid waking up the child perched on her waist. I placed my hand on her shoulder. It won't be long now. She replied softly. I know.

I sat for a few moments and waited. The breaths became less and less frequent. Then suddenly they stopped. The woman shuddered. Mutely shaking she sobbed. Visceral, uncontrollable movements made more powerful by there silence.

From the distance I could here a kitschy lullaby on the PA system. Somewhere in the obstetrics ward a baby had just been born. I remembered a poem by John Donne:

Each man's death diminishes me,
For I am involved in mankind.
Therefore, send not to know
For whom the bell tolls,
It tolls for thee.


Cameron has fallen behind. He stops to tie his shoes. My thoughts sprint forward without the distraction of companionship.

Father and son. Doctor and grieving family member. Above the fray and yet bruised and broken below the surface.

I am all of these.

Cameron clanks ahead and the sun catches the tail of his scooter and blinds me momentarily. I stop and bend forward my arms resting on my knees. My calfs exploding. My heart flubbing. And my brain longing for the sweet reconciliation and abandon of sleep.

He pauses a few feet ahead and cranes his neck backward. can't stop now!

His words are like daggers filleting open my torso and exposing a deep, primal be told what to do.

My legs respond despite the minds abrasive litany of curses.

Despite all that has happened today.

I will continue running.

Thursday, August 25, 2011

Sometimes Our Healthcare System Is Like This

Sometimes our healthcare system is like this:

I'm sitting outside a restaurant eating lunch with my brother and cousin. Out of the corner of my eye I see a woman fall.

Her wrinkles and unsteady gait betray her youthful facade. A cane bounces against the building and lands next to her. She is disoriented. Confused.

We jump out of our chairs and turn around. A flash of blazing cell phones connected to shaky hands greets our arrival. Multiple bystanders cry out in unison...we're calling 911.

The lady sits up and leans against the side of the building. Her eyes regain clarity...No...don't...I'm OK!

The cell phones recede but the crowd is restless. They form a circle around their prey ready to pounce. Are you OK? Did you hit your head? Does your hip hurt? With each question the anxiety level rises. I try to clear a path. To give her space.

We hoist her into a chair. She is beginning to recover. The owner of the restaurant hands her a glass of water.

A young athletic women bursts through the crowd. She grasps her cell phone like her hands are the jaws of life pulling an accident victim out of a car crash. She is almost yelling....I just want you to know an ambulance is on the way! She speaks into the air. To no one in particular.

As the fire truck and ambulance arrive the poor women quietly shakes her head. didn't want this.

She slouches nonchalantly and listens as the EMT tries to convince her to go to the hospital. But...I'm okay...really.. I'm okay. I just slipped while trying to get up.

They force her to sign a medical release and then the ambulance and fire truck slink away quietly.

With little hesitation. The women leans over the cain and propels herself out of the chair. She hobbles across the alley...her hips swing comfortably side to side. She walks fifty more feet and then enters a medical complex.

Even with the twenty minute delay at the restaurant...

She will be right on time

for her orthopaedic appointment.

Monday, August 22, 2011


She comes to me. On a cold winter day. Hobbling into the office. She carries her walker with the indifferent embrace of a despised relative. She unpeals the layers. First hat and scarf. Then over sized down coat. Daintily she removes her sweater.

I ask what hurts...and she tells me.

She tells of the serpent slithering through her spine. Squeezing her insides and spitting venom towards the thighs. She tells of mal-lubricated joints and the fecundity of aging.

She tells me of her late husband...and how he was a "good man". Regret dabbles at the corners of her lips...toying with the idea of springing forth but reticent.

She tells me of her mother in law. Handicapped and depressed. A miserable soul who spent a decade cloistered in her guest bedroom. Her voice says....I would never burden my children...although the words will remain unspoken.

And she tells me of a man. Who she dated as a teenager. Who fought in World War II and sent a letter proposing marriage. She still doesn't know why she declined. Although he survived the war....their love did not.

On days like today she often wonders. Is he alive? Alone, arthritic, in a doctors office like herself.

I wait for her to continue. My impotent stethoscope rests in my coat pocket. A cabinet feet away is filled with samples of drugs to cure most any malady.

Today I will slough off the bloated title of healer...drug pusher...fortune teller.

I will sit back. Ignore the light buzz emanating from the computer. Fail to answer the persistent vibration of my pager.

Abandon myself to anther's needs....

and I will listen.

Thursday, August 18, 2011

The Jury Is Still Out

I heard his body crumple before the commotion began. Nurses scurried to and fro. I looked up cautiously from my charts...I was the only doctor in the building.

I placed my charts in a neat pile and nonchalantly walked over. Noticeably absent was the sense of adrenaline. The fear. This was just another day at work.

The sea of nurses parted and I knelt down next the aged man. My fingers reached for his carotid pulse. His chest was moving rhythmically up and down. I placed an oxygen cannula on his nose and checked his blood pressure. Nothing was amiss.

After a moment his eyes began to flutter. We hoisted him into a chair and he was returned to his room for further assessment.

And as I sat down to return to charting I felt a certain sense of satisfaction. I was a seasoned pro. I could handle a crisis without even breaking a sweat. Look how far I had come since medical school!

Look how far I had come? As I write these words I feel a sense of shame rise through my torso and chest.

Since when has nonchalance become OK? Isn't the sense of fear, the adrenaline, the heart racing that makes us most human as doctors? That binds us to our fellow man.

For better or worse...we are not robots. We are deeply scarred individuals with foibles and peculiarities. When cut we bleed...just like our patients.

And when a person falls in front of me suffering form a heart attack...or stroke...or god knows what...shouldn't my pulse run, my brow sweat, my heart skip a beat.

Because when death, and pain, and suffering become part of our routine then we have lost that vital connection between those who care and those who are cared for.

I have come a long way from the innocent boy who started medical school. Who became faint at the site of blood...whose adrenaline raced with each new trauma.

But have I become a better human being?

The jury is still out.

Tuesday, August 16, 2011

The Art of Differential Diagnosis.

I awkwardly unscrewed the top off the dishwasher door. The two young women stood above me approvingly. I acted like I knew what to do.

It was a new machine but I already drove out twice in the last six months. Damn latch. I didn't have the heart to tell the girls that I couldn't fix it. Or to explain how, as a child, I avoided the cabinets full of tools that my father left behind when he died. So much material but no capable hands to teach me how the hell to use it.

So I grew up in a mother centered household. We didn't fix things. We called someone.

As I pulled the cover off the door my mind raced back to the office. To the image of the uncoordinated violinist.

She taught music until the economic downturn. Saddled with impatient debt and screaming debtors she started to perform regularly. Until the day she noticed something wrong.

I glanced blankly at the guts of the washing machine door. Gently I eased the latch out of its compartment and glared. Why was it stuck?

My violinist had lost control of her left index finger. Try as she might...she couldn't play the challenging pieces. The finger was lame...dumb. Slowly responding to the music while the others raced ahead obliviously. But the index could no longer keep pace on the finger board.

The latch was being held back by a catch. A safety mechanism perhaps?

I stared into her eyes. Her pupils were reactive. I weaved and bobbed through the neurological exam noting no abnormalities. At last I came to the hand. I compressed each nerve in the wrist carefully and watched for a response. Her pulses were normal. Then I asked her to place both hands on the exam table face up.

I greased the catch with DW40. It still wouldn't release the latch. Finally I removed the spring from the catch and watched it fall to the side. The latch now moved freely.

After concentrating for a few minutes I noticed it. A lump in her left wrist. It was small but placed perfectly to impinge on the long tendon that races through the hand and ends at the tip of the index finger.

I suspected a ganglion cyst. A quick procedure by the hand surgeon and her finger would dance again.

It took another thirty minutes to remember how to fit the latch back in and then screw the top on. I watched with satisfaction as I closed the door.

Flipped the latch...

and started the dishwasher.

Thursday, August 11, 2011

The Plan

He came to the office with an idea.

He came to the office with a plan.

Because his mother told him that a cough could be a sign of cancer. And his wife reminded him of his history of smoking. And his cousin's friend's sister's fiance's grandfather had died and his doctor hadn't bothered to get a cat scan.

He refused to entertain questions. He dodged and darted to avoid my probing stethoscope. He asked for...nay demanded a cat scan.

He was unperturbed when his symptoms magically disappeared with an antacid. He was downright sullen when I warned of the risks of radiation....when I cautioned about incidentalomas.

So in Berwickian fashion I gave in. I ordered the cat scan. I waited.

It was a lung nodule. To big to ignore. Reluctantly I offered biopsy.

He wanted to see a pulmonologist. The pulmonologist offered biopsy. He wanted to see a cardiothoracic surgeon. The surgeon offered the same.

After many phone calls and much discussion and great trepidation he entered the radiology suite for a ct guided biopsy.

He left with a chest tube....a short hospital stay....and the most physically painful experience of his life.

On the day of discharge I entered his room with good news.....It's benign

Benign....great. And then he paused a moment. Maybe we should take it out anyway.

I want to see the cardiothoracic surgeon!

Tuesday, August 9, 2011

A Covenant

I mean it is kind of lonely....being your doctor. I picture it as sort of a covenant. Between you and I.

On one side you. And your family. And friends. Your house and your dogs. Your communities and lives.

On the other side me. Alone. Of course there is always the hospital...but were really not friends. My partners and specialists. They all make an appearance. But when the going gets tough.

I am like an island. That you inhabit from time to time. Occasionally good times. Often bad. And I pray that there is enough of me to sustain. For there are rarely other visitors. Rarely extra provisions.

My island floats independently in the sea. I face each brutality and hardship with you. But since I am land and you are my inhabitants we often see from very different perspectives.

When you hurt, and suffer, and die. You call. And sometimes from the depths of hibernation I answer. My eyes twitching in the darkness as I try to decide whether to give more lasix or should I try fluids? There is no nephrologist in the bed next to me. No cardiologist. And if there were would they remember the time your shortness of breath was anxiety? Remember the time your anxiety was a heart attack?

You pray that I make the right decision. Did you know that I pray to? Pray that tonight I will be less fallible. Pray that I will remember each piece of imminent minutia. Unlock the bodies tenuous riddles and splay them out in front of you as if they were a healing potion. A soothing balm

Each covenant ends the same. Either you or I will die. Your suffering over and your family mourning.

And I will Remain. Alone. Fighting to provide for the other two thousand inhabitants of my island.

Each one a covenant...

Each one signed with a golden quill...

signed in my own blood.

Monday, August 1, 2011

As I walked Into....

As I walked into the store an old memory rushed into the corners of my consciousness.

Mary had a little lamb....little lamb...little lamb

There I sat. A young boy with a recorder on my lips. My fingers dutifully covering and then uncovering the holes on the long end of the instrument. I was in elementary school. It would be the first and last instrument I ever played.

I started strongly. In the beginning. Far ahead of my classmates. Under my mother's tutelage I practiced each and every day. But eventually something happened.

I became bored. Or tired of the monotony. My heart wasn't really in it. The teacher quickly noted the change. My skills faltered. The class moved forward and the turtles passed the hare...

I skipped my only concert.

But now I entered the store on my own volition. A few months earlier Cameron and I had made the same journey. The store clerk sized him up and handed us a violin and bow to try on for size.

Father and son stood together. Tentative at first. Eyes wide to marvel the beautiful instrument that had been placed in his little unsteady hands.

The next week he started lessons. As I sat in the corner of the small study the teacher first instructed Cameron and then turned her attention to me. She gave tips on how to moniter, how to hold the violin, how to angle the bow.

And we learned...Cameron and I. Over months he began to adjust to the weight of the bow, the tension of the strings. I stood over him. I listened to the plink and pluck, the ebb and flow. At times picking up the miniature violin and instructing on what I perceived to be the right stance. I moved the bow back and forth awkwardly my body curled to meet the requirements of such a small instrument.

I found myself looking forward to every evening session. Whistling the tunes as Cameron learned them. My voice straining to the highest E or groaning to the lowest G. A great peace overcame me.

So it was really not very surprising this afternoon when I pulled over upon passing the store on my way home from work. The clerk greeted me energetically.

Are you picking something up for your son?

No! I answered without hesitation...

I was hoping to rent one for myself.