In my line of work I confront the inevitable daily. On more challenging days every 15 minutes can bring another life altering revelation. Enough water has passed under my bridge that prognosticating is less subjective then it use to be. Numbers tell the story of kidney, liver and pancreatic function, of blood sugar and fat and thyroids. The ultimate measure is blood pressure, only five (hopefully not six) digits and a /.
Across from me the numbers sit. I am amazed how many people will pay the co-pay for a sniffle but are unwilling to make the same commitment for diabetes, hypertension, elevated cholesterol and the various diseases that stem from them.
Contrary to the prevailing wisdom, each encounter is custom made. Even if you do not realize it you are being a fitted for haute couture or tailored for a suit from Saville Row. The doctor is someone who has devoted their life to their craft and so many hours that most are enigmas even to their families. It is not often you bump into such expertise and think so little of it.
With my time in practice now measured in decades I spend the visit watching for subtle signs of disease. Of course much of what I do has nothing to do with a patient’s well being but instead with placating legal, governmental and insurance bureaucracies. But today I am thinking about the patient—with their numbers—sitting across from me.
I watch and listen. I lay on hands and stethoscope. I gaze into various orifices, and look at slides of secretions and peruse the numbers on the screen in front of me. If we had a past visit I hope the specialist’s recommendation made it into the electronic medical record, as well as any tests results. And then I sit back (not too far as I am only on a stool) and in the few seconds allotted to me, put the above into context, offer a plan and wait for feedback.
In the past few years this process has been derailed. Now in many encounters the process is reversed. Patients have been empowered by Google. The plan comes first and the person waiting (or not) is the patient not me. I respond in various ways to this depending on first impressions, as I have not been able to follow my usual protocol.
If the patient is hale and hardy but convinced they have an exotic wasting disease I have been known to chuckle. It is not intentional. It just has to do with the shear improbability of the situation. I know I should not discount their concerns but I also know there is no reality to this encounter. Often their concerns lead to demands for specific tests. Many of which I have never heard of or have no idea of how to order.
Medicine is a scientific art. Ask any real scientist and they will tell you that most physicians practice a black art. I agree with them. Several things that set aside a MD/DO from a Ph.D. are the need to make time constrained decisions and the fact that biology is fickle, no double blind controlled studies here. This is best represented, in its most extreme form, by a Code. It is the situation that most unnerved me as an intern. And I am not just talking about the heart related codes. There are also Code Whites for violent behavior and Code Reds for fire. Each presents a different challenge.
This brings to mind the several months I worked as an intern at a particularly dysfunction, now defunct hospital. I would manage to drag myself to the call room for an hour’s fitful sleep after a night laboring on the floors. Without taking off my scrubs I’d fling myself onto the grubby bed inhabited by the ghosts of interns past. With eyes forced shut I tried to ignore the ever-present list of tasks that resided in my pocket. For a few minutes before the sun crept up onto the surface of Lake Michigan I hoped to sleep.
Each night that I was on call, just as I dosed off a heavily accented voice would announce a Code Red. The implausible certainty of this was maddening. To complicate matters further sirens could be heard far off in the distance. Why am I telling you this, because I had to make a decision: ignore what was in all likelihood a false alarm and catch twenty minutes of shut eye, or burn up in my sleazy little bed.
Ask your self, what would you do. Remember, put it the context of not having slept for several months, of being sticky and dirty from the 36 hours of work, of having gunky stuff in the corner of each eye and greasy hair. Context is every thing. What did I do—I got up, usually in time for the code to be called off. By then sleep was impossible. Like a zombie I wandered back into the hospital, pulled the list out of my pocket and pickup where I left off.
Another time at a more collegial institution I tucked myself in for what would be on most nights a more reasonable sleep. There were nights here where I even dreamed, that is when my fellow cellmate wasn’t fending off the occasional mouse. But one night, with the beginnings of REM fluttering in my eyes, a Code White was called on the psychiatric unit. This along with rehab and the telemetry units were my responsibility.
No hesitation this time, I got up and made my way to the sequestered corner of the hospital that housed the psych unit. Its design was fatally flawed. The nursing station was located in the rear and even though I pounded on the door no one responded. Worried now but with intimate knowledge of the layout I entered through a common door from the pediatric unit (another fatal design flaw).
Once there I joined forces with the security guard, and several large male and one petit female nurse. As most interns figure out, you have the ultimate responsibility with the least experience. The fact of being thrust into this position builds character and depending how you handled yourself, respect.
The Code White was due to a large ferocious male patient. He had threatened the staff and with some effort had been corralled into a small room. Now he was threatening to break out and create more havoc. Eyes turned towards me. I was so tired that any lack of confidence faded away and I made a quick decision. A syringe was loaded up with Haldol, given to the petit and agile nurse, and the rest of us stormed the patient and subdue him. He rapidly calmed down and I was left to salvage what I could of the few remaining hours before life returned to the hospital.
My training was full of decisions. It was inevitable. I draw upon them now as I sit across from my patient. I wait for a response to my entreaties. I know that inescapable results will follow. My mind’s eye sees the future playing out. If I get the wrong answer my heart pangs. I have not gotten through to them. I failed and I express it, often in the stark language of disease.
I think of the procedures, of wasted time and treasure, of shortened lives. I am not always right, but more often right then wrong. I have experience on my side. But life goes on, and I have had to become somewhat immune to pain and suffering. It is inevitable after all. Gautama Buddha taught us this thousands of years ago.
May 2012
