A Life in Medicine

by Robert Coles

  Bent on her knees

  Stretched up her arms

  Then leaned back and sat down

  Lifted her knees as in

  Stirrup for childbirth

  Book after hardbound book

  Looking for a gush of water

  Found one

  This one

  Splash of a waterfall

  Look at this one

  Pointed him to it

  The illness there

  Their respirations now fast

  The illness of their child

  Described with paragraphical details

  Graphs and diagrams

  Percentages and prognoses

  They looked

  Side to side

  Held their breath

  So as not to be caught

  In their act

  Not to be scolded

  In their act of love

  Their moment of near death

  The inner sanctum

  Stacks on stacks

  Of well-worded knowledge

  Of medical texts

  An act of suspicion

  That would confirm or deny

  What the doctors told

  PART THREE

  Physicians Must Be Skillful

  PHYSICIANS must be highly skilled in providing care to individual patients. They must be able to obtain from their patients an accurate history that contains all relevant information; to perform in a highly skilled manner a complete and a limited, organ-system-specific, physical examination; to perform skillfully those diagnostic procedures warranted by their patients’ conditions and for which they have been trained; to obtain, interpret properly, and manage information about laboratory and radiology studies that relate to the patient’s conditions; and to seek consultation from other physicians and other health care professionals when indicated. They must understand the etiology, the pathogenesis, and the clinical, laboratory, roentgenologic, and pathologic manifestations of the diseases or conditions they are likely to confront in their practice of their specialty. They must also understand the scientific basis and evidence of effectiveness for each of the therapeutic options that are available for patients at different times in the course of the patients’ conditions, and be prepared to discuss those options with patients in an honest and objective fashion. Physicians must also be able to communicate with patients’ families about all their concerns regarding the patients’ health and well-being. They must be sufficiently knowledgeable about both traditional and nontraditional modes of care to provide intelligent guidance to their patients.

  David Nash

  THE TALLIS CASE

  What is it like to make house calls on people who are “too poor for a society doctor but too proud for the clinic”? In this essay, David Nash recounts working diligently to provide in a highly skilled manner a physical examination of “an ancient Jew” in his home—and what happens when he tries to offer a therapeutic option he strongly believes may save his elderly patient’s life. The physician in “The Tallis Case” discovers the rewards of treating the patient in his own world.

  DAVID NASH, a board certified internist, is the founding director of the Office of Health Policy and Clinical Outcomes at Thomas Jefferson University and an associate professor of medicine at Jefferson Medical College in Philadelphia. “The Tallis Case” appeared in the JAMA column “A Piece of My Mind.”

  I approach my responsibilities of teaching cardiology to medical students and house officers with some ambivalence. Of course, I have always enjoyed and usually learned something from my contacts with these young colleagues, but lately their emphasis seems to be entirely on technical procedures. Few of my charges express an interest in entering full-time solo practice; most are not enthusiastic about honing their skills in bedside physical diagnosis. None believes in house calls.

  I can remember making house calls on people who were too poor for a society doctor but too proud for the clinic. My mind can still conjure up the kind of call I’d get, almost always at night.

  “Doctor, can you come? Quick! It’s Zadhr, he’s not feeling too good.”

  “What seems to be the trouble?”

  “How should I know? He just doesn’t feel good. Please come.”

  It was usually more a plea than a command. I’d roll over to the side of the bed and fall into my clothes. Bleary-eyed, I’d stagger to my car and fume because it started so slowly in the cold. Heated garages were an unachieved luxury when I started in practice. Somehow I’d find the address, although more often than not I’d get lost in the process. About the time I was cursing under my breath, I’d spot the telltale light and an anxious kerchief-clad face at the window, one hand pulling the curtains apart for a better view.

  “You’re the doctor?” would be the greeting, punctuated by lifted eyebrows and a faint grimace of disbelief. I looked young for my age. People trusted older, more experienced doctors in those days.

  “I’m Dr. Nash. Where’s the patient?” I usually preferred to get right down to business, considering it was the middle of the night.

  “What’s your hurry? Take off your coat. Zadhr is in the bedroom.” The ancient female before me was annoyed. It was obvious to her that youths no longer concerned themselves with manners, and she didn’t really approve of young pishers passing themselves off as real doctors, even if one could not pay.

  Her eyes spotted my little black bag and she seemed reassured for the moment. She heaved a sigh, somewhere between a grunt and a wheeze, and led the way.

  The house was of typical frame construction, two-storied and of pre–World War I vintage. The banisters that led up to the master bedroom were hand carved and glistened with a dark patina of hardwood and years of furniture polish. A threadbare runner led up the stairs. At the top I could hear the sounds of respiratory distress.

  The ancient Jew sitting bolt upright in bed against several down pillows looked regal with his white beard and long sideburns. His nightclothes were white, and a small yarmulke adorned his gray, tufted scalp. Dark, bright eyes burned at me through the somber dimness of the room lit by a single 60-watt bulb. He offered no greeting or complaint, just a long soul-piercing stare. I was mesmerized for a moment, and then the noise of his breathing broke through my consciousness and I knew I had my hands full.

  My physical examination was brief and confirmatory. The old man was in severe congestive heart failure. He was literally drowning in his own juices.

  “Did he eat anything salty?”

  “Nothing. A little schmaltz herring; a bowl of chicken soup; he doesn’t eat enough.”

  She could not see me wince. Wisely, I stopped myself from explaining the reality of salt restriction to an old Orthodox matriarch who was salting flesh before I was born.

  Well, at least I knew what had to be done.

  “He has to go to the hospital. Where’s the phone?”

  “No!” It was the only word Zadhr had said. It did not brook discussion, but I wasn’t quite wise enough to realize that.

  “Look,” I started, speaking a little louder than necessary to emphasize my conviction and the academic knowledge that my professors had assured me would carry the day once I got into practice. “Look, he’s in heart failure. I can treat him better in the hospital. It’s important.”

  “Doctor, you heard my husband. He doesn’t want to go. Treat him here.”

  I knew further negotiations would be fruitless. I gave him digoxin, a diuretic, and a shot of morphine, but he was still working too hard breathing. Then my training finally came in handy. I told the old lady what I needed. With hesitation she went to the kitchen and cut the cord away from the curtains. I arranged the tourniquet around the old man’s arms and legs. With the blood trapped in his extremities, he began to breathe better again.

  During the next several hours, his congestive heart failure abated. Finally he dozed off, able to lie flat again for the first time in a week.

  The old lady had given me several cups of tea during the long night’s
vigil, so I was wide awake when dawn broke. Convinced that the patient would survive, I turned to go. At the door she pressed something in my hand and murmured an awkward thanks.

  As I started the engine, I opened the brown paper wrapper. Inside was a hand-embroidered tallis case, its velvet worn by a lifetime of weekly use.

  I wonder how many of my students will feel as rewarded for their efforts.

  Abraham Verghese

  from MY OWN COUNTRY

  In 1985, the first AIDS patient in Johnson City, Tennessee, was rushed into the Johnson City Medical Center intensive care unit to the horror of everyone in this isolated part of the country. This excerpt from Verghese’s book My Own County: A Doctor’s Story of a Town and Its People in the Age of AIDS is a breakneck account of the arrival of a national epidemic in the Smoky Mountains and of the deep suspicion and fear it aroused at a time when the medical community was only dimly aware of acquired immune deficiency syndrome, let alone its etiology or the “effectiveness for each of the therapeutic options that are available for patients” afflicted with AIDS.

  As much a vivid, firsthand account of moment-by-moment life in the emergency room as it is a description of a turning point in the history of the AIDS epidemic, this excerpt shows the agonizing limits of doctors’ skillfulness in the face of unknown disease, and the fears such lack of skill and knowledge produce in an entire community.

  ABRAHAM VERGHESE is a specialist in infectious diseases in El Paso, Texas, where he is a professor of medicine at Texas Tech University. He is the author of The Tennis Partner, an excerpt from which appears elsewhere in this anthology.

  Summer, 1985. A young man is driving down from New York to visit his parents in Johnson City, Tennessee.

  I can hear the radio playing. I can picture his parents waiting, his mother cooking his favorite food, his father pacing. I see the young man in my mind, despite the years that have passed; I can see him driving home along a route that he knows well and that I have traveled many times. He started before dawn. By the time it gets hot, he has reached Pennsylvania. Three hundred or so miles from home, he begins to feel his chest tighten.

  He rolls up the windows. Soon, chills shake his body. He turns the heater on full blast; it is hard for him to keep his foot on the accelerator or his hands on the wheel.

  By the time he reaches Virginia, the chills give way to a profuse sweat. Now he is burning up and he turns on the air conditioner, but the perspiration still soaks through his shirt and drips off his brow. His lungs feel heavy as if laden with buckshot. His breath is labored, weighted by fear and perhaps by the knowledge of the burden he is bringing to his parents. Maybe he thinks about taking the next exit off Interstate 81 and seeking help. But he knows that no one can help him, and the dread of finding himself sick and alone keeps him going. That and the desire for home.

  I know this stretch of highway that cuts through the Virginia mountains; I know how the road rises, sheer rock on one side, how in places the kudzu takes over and seems to hold up a hillside, and how, in the early afternoon, the sun glares directly into the windshield. He would have seen hay rolled into tidy bundles, lined up on the edges of fields. And tobacco plants and sagging sheds with their rusted, corrugated-tin roofs and shutterless side-openings. It would have all been familiar, this country. His own country.

  In the early evening of August 11, 1985, he was rolled into the emergency room (ER) of the Johnson City Medical Center—the “Miracle Center,” as we referred to it when we were interns. Puffing like an overheated steam engine, he was squeezing in forty-five breaths a minute. Or so Claire Bellamy, the nurse, told me later. It had shocked her to see a thirty-two-year-old man in such severe respiratory distress.

  He sat bolt upright on the stretcher, his arms propped behind him like struts that braced his heaving chest. His blond hair was wet and stuck to his forehead; his skin, Claire recalled, was gun-metal gray, his lips and nail beds blue.

  She had slapped an oxygen mask on him and hollered for someone to pull the duty physician away from the wound he was suturing. A genuine emergency was at hand, something she realized, even as it overtook her, she was not fully comprehending. She knew what it was not: it was not severe asthma, status asthmaticus; it was not a heart attack. She could not stop to take it all in. Everything was happening too quickly.

  With every breath he sucked in, his nostrils flared. The strap muscles of his neck stood out like cables. He pursed his lips when he exhaled, as if he was loath to let the oxygen go, hanging on to it as long as he could.

  Electrodes placed on his chest and hooked to a monitor showed his heart fluttering at a desperate 160 beats per minute.

  On his chest x-ray, the lungs that should have been dark as the night were instead whited out by a veritable snowstorm.

  My friend Ray, a pulmonary physician, was immediately summoned. While Ray listened to his chest, the phlebotomist drew blood for serum electrolytes and red and white blood cell counts. The respiratory therapist punctured the radial artery at the wrist to measure blood oxygen levels. Claire started an intravenous line. And the young man slumped on the stretcher. He stopped breathing.

  Claire punched the “Code Blue” button on the cubicle wall and an operator’s voice sounded through the six-story hospital building: “Code Blue, emergency room!”

  The code team—an intern, a senior resident, two intensive care unit nurses, a respiratory therapist, a pharmacist—thundered down the hallway.

  Patients in their rooms watching TV sat up in their beds; visitors froze in place in the corridors.

  More doctors arrived; some came in street clothes, having heard the call as they headed for the parking lot. Others came in scrub suits. Ray was “running” the code; he called for boluses of bicarbonate and epinephrine, for a second intravenous line to be secured, and for Claire to increase the vigor but slow down the rate of her chest compressions.

  The code team took their positions. The beefy intern with Nautilus shoulders took off his jacket and climbed onto a step stool. He moved in just as Claire stepped back, picking up the rhythm of chest compression without missing a beat, calling the cadence out loud. With locked elbows, one palm over the back of the other, he squished the heart between breastbone and spine, trying to squirt enough blood out of it to supply the brain.

  The ER physician unbuttoned the young man’s pants and cut away the underwear, now soiled with urine. His fingers reached for the groin, feeling for the femoral artery to assess the adequacy of the chest compressions.

  A “crash cart” stocked with ampules of every variety, its defibrillator paddles charged and ready, stood at the foot of the bed as the pharmacist recorded each medication given and the exact time it was administered.

  The clock above the stretcher had been automatically zeroed when the Code Blue was called. A code nurse called out the elapsed time at thirty-second intervals. The resident and another nurse from the code team probed with a needle for a vein to establish the second “line.”

  Ray “bagged” the patient with a tight-fitting mask and hand-held squeeze bag as the respiratory therapist readied an endotracheal tube and laryngoscope.

  At a signal from Ray, the players froze in midair while he bent the young man’s head back over the edge of the stretcher. Ray slid the laryngoscope in between tongue and palate and heaved up with his left hand, pulling the base of the tongue up and forward until the leaf-shaped epiglottis appeared.

  Behind it, the light at the tip of the laryngoscope showed glimpses of the voice box and the vocal cords. With his right hand, Ray fed the endotracheal tube alongside the laryngoscope, down the back of the throat, past the epiglottis, and past the vocal cords—this part done almost blindly and with a prayer—and into the trachea. Then he connected the squeeze bag to the end of the endotracheal tube and watched the chest rise as he pumped air into the lungs. He nodded, giving the signal for the action to resume.

  Now Ray listened with his stethoscope over both sides of the chest as the respiratory
therapist bagged the limp young man. He listened for the muffled whoosh of air, listened to see if it was equally loud over both lungs.

  He heard sounds only over the right lung. The tube had gone down the right main bronchus, a straighter shot than the left.

  He pulled the tube back an inch, listened again, and heard air entering both sides. The tube was sitting above the carina, above the point where the trachea bifurcates. He called for another chest x-ray; a radiopaque marker at the end of the tube would confirm its exact position.

  With a syringe he inflated the balloon cuff at the end of the endotracheal tube that would keep it snugly in the trachea. Claire would tape around the tube and plastered it down across the young man’s cheeks and behind his neck.

  The blue in the young man’s skin began to wash out and a faint pink appeared in his cheeks. The ECG machine, which had spewed paper into a curly mound on the floor, now showed the original rapid heart rhythm restored.

  At this point the young man was alive again, but just barely. The Code Blue had been a success.

  In no time, the young man was moved to the intensive care unit (ICU) and hooked up via the endotracheal tube to a machine that looked like a toploading washer, gauges and dials covering its flat surface. Its bellows took over the work of his tired diaphragm.

  He came awake an hour later to the suffocating and gagging sensation of the endotracheal tube lodged in his throat. Even as the respirator tried to pump oxygen into his lungs, he bucked and resisted it, tried to cough out the tube. One can only imagine his terror at this awakening: naked, blazing light shining in his eyes, tubes in his mouth, tubes up his nose, tubes in his penis, transfixed by needles and probes stuck into his arms.

  He must have wondered if this was hell.

  The Miracle Center ICU nurses who were experienced—at least in theory—with this sort of fright and dislocation, reassured him in loud tones. Because of the tube passing between his vocal cords and because his hands were tied to prevent his snatching at the tube (an automatic gesture in this setting), he could not communicate at all. With every passing second, his terror escalated. His heart rate rose quickly.