Thursday, June 21, 2012

Paging Dr. Einstein

About a year ago, I was having lunch with a friend when the subject of finding a good doctor came up.  What makes a good doctor?  What qualities are most valued?  My friend leaned forward and asserted, “I really don’t care if my doctor is nice and all that stuff, I just want the freakin’ smartest doctor I can find.”  I pressed my lips into a half-smile.  I didn’t agree with her at the time, but I found my ability to counter lodged somewhere between my heart and my throat.  The truth is, when I started medical school, I felt much the same way.  Who cares if a doc pats you on the shoulder and comforts you?  Who cares if she smiles and asks you about your wife, kids, and pet zebrafish?  To me, all this was much like the toy that comes with your kid’s meal—a delightful bonus, but not the real substance of medicine.  I just wanted someone to do the right tests, give me the right meds, and send me on my way—fixed up and ready to go.  But even in the first few months of my training, I could see that my initial impression of good medicine was rather short-sighted.  It seemed odd that on one hand, I was a proud member of a fraternity that prides itself on stratospheric test scores and intellectual acrobatics.  Yet on the other hand, I was beginning to see that brute intellect plays only a small supporting role in medicine’s celebrated script.  For many of us, this comes as a hard pill to swallow.  But the truth is it doesn’t take a genius to be a great doctor.
Part of the problem for both patients and providers alike is that we often view illness as a technical difficulty. If our computer crashes, we expect the whiz at Apple to uncover the problem and provide the restorative reboot.  If our car crashes, find us a skilled mechanic who can dive under the hood and give it new life.  Hell, if the economy crashes, we believe the officials we elect to office should have the power to tweak a few policies, rejigger the interest rate, and get our GDP rocketing skyward again.  And why not?  We are of a bold generation that has always viewed even the most complex problems as a giant brain away from happy resolution.  But what if a loved one gets sick?  And what if it’s my child—not my computer—who’s crashing?  Often, our initial intuition is the same.   Employ the smartest doctor in the hospital to swap a few meds, execute some elaborate surgery, and restore everything back to normal.  A doctor’s job is to fix our cracks and mend our leaks so we can get on with our lives.  And presumably, the smartest ones are also the best fixers.  But of course, matters of life—and death—are never quite so simple.
Despite whatever value we assign to our beloved gadgets, laptops don’t think, and cars don’t feel.  They also don’t dream, aspire, believe, defy, invent, or imagine.  It’s the fingers that touch a keyboard that possess the ability to translate the ideas and emotions of a brazen mind.  Cars carry passengers, but it’s the passengers who carry a lifetime of joys and sorrows.  And when an economy crashes, it’s the people who suffer, not the GDP.  So while flawed devices and failed policies can be restored and renewed, they can also be discarded.  Human beings—well, not so much.  This is the real grit of medicine.  We can preserve health, but not indefinitely.  We can treat pain, but we don’t cure misery.  Despite all our medical advances, more often than not, our job is not to fix, but to advise, to advocate, and to comfort when suffering has already established a foothold.  The brilliant engineer must decipher when old parts should be abandoned and outdated systems replaced.  The great physician—she must walk with the worn, and sit with the broken.  And it’s not that we should disregard the breadth of her knowledge.  It’s just that there is truly no replacement for the depth of her compassion.
For those of us who still view illness as technical blip, it’s likely because we have never been truly sick or cared for the gravely ill.  Yes, we’ve probably taken antibiotics for a throat infection or received x-rays for a broken bone.  Maybe even gone through surgery and rehab for certain injuries.  But the most common and costly diseases afflicting Americans are the unsexy, life-sapping diagnoses that prompt years, even decades, of suffering.  Diabetes, depression, heart disease, cancer—all chronic diseases without cure.  If you spend enough time around doctors, you will hear them refer to treatment as “medical management.”  Because in cases of long-standing illness, it isn’t about coming up with dazzling answers or pondering over a mysterious case until reaching that single “aha!” moment.  You work with patients to juggle a dozen prescription pill bottles.  You remind patients why they can’t eat their favorite foods—the ones they’ve grown up enjoying.  You even prepare patients for how chemotherapy will cause them to lose their hair, their hearing, their sex drive, and much of their independence.  And you help them understand why once your health leaves you, it doesn’t often come back.   Because for patients whose lives are marred by poor health, medicine becomes more about dedicated support, compassionate care, and constant education.  It turns out the ability to perform high-flying mental acrobatics is really just a bonus.  Like that toy that comes with your kiddy meal.  When you are truly famished, your focus shouldn’t be on the toy.
The truth is that for many patients, they come to a doctor sick, and leave sick.  And for 365 days a year, they are the ones taking care of themselves.  Physicians don’t get to play miracle healer as often as they’d like.  Instead, the challenge is how to better empower patients to choose for themselves the lives they want to live, even when illness has become a part of everyday reality.  I know if someone I really cared about got sick, there are some people in my class I would trust without hesitation.  Not because they are brilliant, though most of them are.  But because they are the type of people that you can trust to carefully guide you while understanding that your diagnosis is not your defining characteristic.  For those who are truly ill, there are often many tough decisions with few good outcomes.  And the “right” decision is different for each individual.  Because after all, we aren’t just a collection of moving parts, all mass-produced from the same mold.  We harbor unique thoughts, values, and aspirations.  And all of these things play into excellent care.  Clearly, amputating a pinky finger might mean one thing to me, and something very different to a concert pianist.  Simply put, there are “good” answers, and then there is true guidance.  The latter is what distinguishes the outstanding physician.  It may not require the gift of pure genius, but it demands a level of human compassion that is perhaps every bit as rare.

Thursday, June 7, 2012

Closure

“It doesn’t have to look pretty,” my resident grinned as he slipped out of the room, pass the sliding glass doors.  I looked up from the half-tied knot that was securing the gown to my waist.  “Alright,” I nodded.  Around me, the whirlwind of alarms that compliments most ICU beds had ceased.  I lifted a needle holder off my patient’s lap, grabbed the needle that had been laid out for me, and loaded it.  The room was now dim, aside from the lamp that hovered at arm’s length above me.  It draped white over my shoulder and onto the wound I was prepared to close.  My gaze slid along the serrated fibers of muscle which framed a crude window cut between two ribs.  There, through the gaping slit in this man’s side, a piece of the lung stared out at me.  And at the top corner of this window, just beneath the breastplate, a fleshy corner of his heart peered out as well.  I lowered metal to flesh and watched the needle take its first bite.  His body was still warm.
Wednesday 9:12 p.m.  My trauma pager had gone off.  Instinctively, I squelched its beeping, shuffled to the nearest elevator, and descended down to the emergency room.  There, I met up with the rest of my team and listened as a nurse on the phone provided updates.  A patient had been found down by the side of the freeway.  He was en route by helicopter.  We stationed ourselves around the designated room, waited, and made small talk.  Fifteen minutes went by.  Then a pale, unresponsive man was wheeled into the trauma bay with a medic crouched above him performing CPR.  “This is a thirty-year-old John Doe… jumped out of a vehicle moving at highway speeds… unresponsive with agonal breathing when first responders arrived… heart stopped beating in transport.”  As the medic gave his report, a curtain of providers descended in a synchronized flurry upon the patient.  From my position at the edge of the room, I watched as the trauma resident grabbed a scalpel, sliced open the chest, swept the lung aside, and began compressing the heart.  The patient’s intrinsic heartbeat returned and within seconds, we were in an elevator on our way to the operating room.
I could hear the steady rhythm of my breaths cycling beneath my facemask.  It was punctuated momentarily by the click of my needle holder as it seized the metal tip at the surface of the skin.  I pulled another stitch through, gave it a tug, and felt the thread bite into my palm.  Slowly, the edges of the wound began to ease together.  Across the man’s chest, the suture spiraled silver—diving in and out, back and forth, from the breastplate to just beneath the nipple before jumping off the skin and onto the needle at the end of my instrument.  The rest of the wound stood open from this point.  It widened underneath the armpit before tapering back down to a corner where the patient’s frame rested against the bed.  I looked at the half that remained open, re-angled the light above me, and continued working.
A bead of sweat dripped down the side of my cheek and dissolved into my facemask.  I fastened one last knot, cut the remaining suture, and set my instruments down.  With a damp cloth, I wiped the dried blood off the newly closed wound.  I stepped out from underneath the lamp light and glanced at the closure.  The suture that held the incision together resembled the seam of a baseball, only knotted within the flesh of this man’s chest.  In some ways, it looked every bit as unnatural as when it lied open with organs visible between flaps of skin and tissue.  I turned toward the door, shed the protective layering I had on, and stepped back into the heart of the ICU.  My resident looked up from his seat.  “I’m done,” I informed him.
Thursday 12:53 a.m.   I propped myself on a step by the patient’s chest.  He had made it through surgery only to have his heart stop twenty minutes after arriving in the ICU.  My resident was calling out orders from his position at the bedside as nurses zipped in and out of the room.  I could hear the practiced calm in his voice.  “Alright, take over,” he instructed, stepping away from the bed while continuing to run the code.  I began chest compressions.  Our attending surgeon slipped into the room, exchanged a few words with the resident, and moved to re-open the patient’s chest.  I took my hands off the breastplate.  Reaching for the lamp above me, I focused it on the thoracotomy.  The attending cut the sutures, spread the ribs apart and reached in.  A nurse handed him a small paddle connected to a defibrillator.  He positioned it on the heart’s surface and everyone stepped away from the bed.  A shock was delivered.  Nothing.  The attending stuck his hand back in the chest and resumed cardiac compressions.  After two minutes, we tried the defibrillator again, followed again by internal CPR.  Still nothing.  “Fuck,” I heard someone whisper.  After nearly thirty minutes the doctor stood up.  “Let’s call it.”  The bustling stopped.  A nurse’s voice floated above the whirring and beeping of machines, “You want me to hold the epi, then?  Okay, we’re calling it.  Everyone, time of death: one twenty-three.”  We all stripped off our gowns and filed out of the room, quietly.
Out of the corner of my eye, I could see where my patient’s body lay beyond the glass pane—motionless under the glow of the examination light I had forgotten to turn off.  My resident stepped into the room, took a cursory look, then popped back out.  “It looks good, man.”  I smiled and thanked him.  It seemed strange accepting a compliment for placing stitches in a dead man.  But before I could mull it over, two women led by a nurse entered the ICU.
One was older, and the other much younger—maybe a mother and a sister.  I couldn’t be sure.  The nurse led them to the room’s entrance, slid the glass door open just wide enough, and whispered something inaudible.  The guests nodded and the nurse stepped away, leaving them alone.  I eyed the older woman as she paused at the doorway.  The younger one—she must have been the daughter—took her mother’s hand and together they stepped into the room.  Both paused a few feet from the bed.  Then deliberately, the sister glided right up to the bedside and slipped her hand over his.  I watched her tremble and for a moment I tried to focus my gaze elsewhere.  Then the sister lowered her face into the man’s shoulder and began to sob.  This time, I looked down at my keyboard and didn’t look back for some time.  But I could hear her faint whimper through the opening in the glass door.
Thursday 2:10 a.m.  I was slouched in front of a computer in the ICU.  My fingers scampered in syncopated bursts across a keyboard and underneath the weight of my eyelids, the ICU faded out… then in… then back out again.  Through this sweet haze of thinly formed sleep, I heard the approaching footsteps of my resident.  “You want to close the thoracotomy?”  The fluorescent lights of the unit rushed back into focus.  “Yeah, I’ll do it,” I heard myself respond.  It was almost a reflex.  I had never closed a thoracotomy before, but as a student, I wasn’t in the habit of passing up such opportunities.  “Okay, everything you need is already in the room when you’re ready.  Let me know if you need help or anything, but it’s pretty simple.  I mean, it’s just got to stay closed.  Don’t worry about making it pretty, you know.”  He picked up a chart and continued walking.
The exam light remained illuminated in the dim room, its single beam never wavering from the wound that I had closed.  Even as family members mourned in the darkness, I could see every insignificant detail of my suture gleaming from behind the glass.  Under the spotlight, the wound seemed to glow as some strange memento of our hollow impact.  All our efforts had amounted to essentially nothing.  And as officials from the coroner’s office sealed the body bag, I held in my head images of his dropping blood pressure, his frenzied surgery, the rosy color of his lung, and the numbers on the clock when we pronounced him dead.  These things I knew, but really I knew nothing.   I knew nothing of how a story of thirty years had unfolded.  Or what thread held together the chapters of a life I had watched unravel in a few dark hours.  I was only there to place the last few stitches, and stand in the shadows as fresh wounds opened in the lives of those who knew enough to mourn.
Eventually, the night faded into nothing, and with it our empty efforts.  Yet all the details remained imprinted in my mind as a reminder of medicine’s harsh reality.  I’ve been lucky enough to stand alongside heroes who pour their hearts and minds into providing some small amount of healing where it is needed most.  I’ve seen them labor and sometimes limp in their efforts to create some meaningful impact in the lives that intersect with their own.  All the while knowing that the stakes are high and their best may in large part be forgettable.  But they push forward in spite of this.  If for no other reason than because it is their singular privilege to do so.

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