Crossings

by Jon Kerstetter

  To the degree that studying the biomedical sciences fascinated and engaged me, studying clinical medicine sobered my rather zealous approach to academics. Clinical medicine required a different kind of knowledge. It focused on real people and the diseases that threatened their lives and the lives of their families. Textbooks didn’t describe the anguish patients felt and often transferred to their doctors. Patients came with fear and anger and tears; they wanted answers and hope and the promise of a cure. And the answers required more than mere recitations of facts about diseases and outcomes. Yes, they needed to yield the hard information about a diagnosis and a prognosis, but they also needed to show compassion in the telling and offer at least some encouragement.

  The lessons on how to provide those answers didn’t come from lectures; they came from hospital rooms and operating rooms and from talking through the tough times with patients and their families. Absent in that milieu was the excitement of the classroom and the laboratories. Of course, seeing a particular disease or its manifestations for the first time was always fascinating in its own way, but observing how disease and trauma made people suffer was itself a kind of vicarious suffering. To become an excellent doctor meant learning to carry that weight.

  In clinical rotations, I honed my skills in taking histories and doing thorough physical exams. I spent extra hours in pediatrics, surgery, and internal medicine. I talked to patients about their diagnoses and prognoses. I watched them struggle, saw some heal, saw some die. Ultimately, what I learned about clinical practice was this: it was not so much the study of a different kind of medicine but more of a transformation into a different kind of person—a healer, a physician.

  Over the three years of my clinical training, I learned to get close enough to patients to show empathy and compassion while remaining detached enough to move from one case to the next with the understanding that medical science could not save every patient. My first lesson in that regard came when Dr. Rhodes, a staff pediatrician, assigned me to follow the case of a small-framed, freckled ten-year-old girl with leukemia who wore a blue bandana to hide her chemo head. I spent hours with the patient and her parents and wrote copious notes in the chart. I read all the latest journal articles on leukemia and hounded the pediatric oncology fellow with questions. My treatment plans detailed the best course of clinical action. She seemed to be responding to treatment, but then a week into the case, a septic crisis hit. She died in the middle of the night. I was shocked by the reversal, feeling that I had at least some responsibility for the outcome, that I should have been able to prevent the untoward complications. I filtered the experience through my role as a father. I imagined how I would feel losing a child to cancer. And in that moment, I felt that being a father made me a more empathetic physician. When Dr. Rhodes saw how the death affected me, she said we had to consider our emotional responses in the context of all the patients we treated, not just the ones we lost; that we as doctors needed to be vigilant against succumbing to despair; and finally, that we were not our patients’ friends or parents: we were their doctors.

  During my initial clinical rotations as a medical student, I thought I would be the kind of doctor who always brought hope and a cure to the bedside. Sometimes that was true. At other times I was the doctor who brought only comfort, and that comfort had to suffice, both for my patients and for me. That was the reality of becoming a physician. It was humbling and frightening and heavy; it was promising and challenging and fulfilling.

  —

  By January of my first year at Mayo, Collin became pregnant. Her due date happened to coincide with my second-year obstetrics rotation, so when the time came, I asked her and my supervising obstetrician if I could deliver our baby. On September 22, 1985, her labor progressed rapidly and by mid-morning, nurses wheeled her into a delivery room. I scrubbed in and the obstetrician talked me through the entire delivery. Playing the roles of father, doctor, and husband left me a bit conflicted. I knew, as a husband, Collin needed me at the head of the bed. I wanted to receive our new baby together and hold her as a father. As a medical student, I wanted the clinical excitement and experience.

  I was so busy with the birth, delivering the head, suctioning the baby’s nose and mouth, and asking my wife for one more push, that when our baby was finally born I forgot to announce we had a girl. The obstetrician chuckled and made the announcement. I cut the cord, clamped it, and handed her off to the nurse. I remember shaking a bit, not from fear, but from joy as a new father. I felt pride as a doctor and a bit of guilt as a husband. I wanted to move between my roles transparently, as if there were no boundaries—to do them all concurrently. I’m not so sure I balanced those roles all that well. But on that day, with our new daughter, I was a doctor and a father and a husband—all three at once, best as I could be.

  Justin and Darren, ages seven and six, and Jordan, age four, were excited for a new sister. The boys wanted to name her Jabba the Hutt, after the Star Wars character. Jordan picked a My Little Pony name. We settled on Katelyn Marie. We have pictures of all four together on the sofa days after her birth, Katelyn rather pink and wrinkled, Justin and Darren with rambunctious smiles, and Jordan hugging her new sister.

  Collin homeschooled the children and kept us more or less organized and on track for family activities. Occasionally we went fishing or picnicking. The boys had piano lessons once a week and participated in the Awana Club at church. They loved the games and Bible stories and treats. Vacation Bible School was a big hit for the kids and it gave Collin a much-needed break.

  A fair number of weekends Collin tended the kids alone because I had clinical rounds or studying. She tried to remind me that weekends were difficult and sometimes lonely, because while most families spent their weekend relaxing, too often she managed the kids alone and had to keep them entertained, disciplined, and fed while maintaining her own space and sanity. Just as I had lacked understanding for the difficulties my mother faced as a single parent, I did not completely understand the emotional and physical toll that medical school took on my wife, who, in many ways, functioned and struggled like a single parent.

  —

  Collin’s parents and my mother attended the Mayo Medical School graduation ceremonies in May 1988. Mom flew in from Salt Lake City wearing her fanciest tan cotton dress and her ceremonial turquois and silver squash-blossom necklace. Her shoes were brown leather flats that she had bought just for the occasion. It was her first trip on an airplane and she told me she wanted to look special for the trip. Her Indian boarding school education had qualified her to work as a housekeeper or a food-service worker. Her labors in those jobs continued past age seventy-five. She never learned to drive a car and always walked to work. She involved herself in her community. One year she won a blue ribbon at the Box Elder County Fair for a homemade cornhusk Indian doll she had entered. She made crazy quilts every winter, peach jam and dill pickles every summer. She brought me a jar of peach jam for a graduation present.

  Commencement ceremonies were held in the Rochester Civic Auditorium. My family and in-laws sat in one of the front rows. After the commencement speech, the dean started calling names for the awarding of degrees. The attendees gave a round of applause. The graduates mostly smiled, but a few had tears welling up. My name was called somewhere near the middle, and I remember walking across the stage and glancing at my family as I went. My kids were smiling. Jordan waved. I waved back. My mother seemed rather somber. In the center of the stage were the dean, Dr. Franklin Knox, and associate deans of the medical school, Drs. Roy Rogers and Gerald Peterson. They presented my diploma, congratulated me, and shook my hand. And in that finite moment, on May 21, 1988, at age thirty-seven, I became the physician I had always wanted to become. Immediately before and after the official granting of my degree, I repeated to myself: I finally made it. I finally made it.

  Afterward, in a private moment during the reception, Mom pulled me aside and pressed an antique silver and turquoise ring into my hand. With tears in her eyes,
she said “God bless” in the Oneida language. She told me how proud she was and how sometimes she wanted to pinch herself just to make sure she wasn’t in a dream. I smiled—said it was a dream.

  Several times that day I opened the special folder that held my Mayo Medical School diploma. Printed after my name were the words “Doctor of Medicine.” I paused in quiet reflection that I had become a doctor, that I was fortunate enough to have had my children and my wife help me with the journey, and that I had come so far from the Oneida Indian reservation where I had begun my life. I remembered my lawnmower ride with Jimmy and my first childhood encounter with doctors. I thought of the country doctor in Utah with the milky-white penicillin and the traditional Oneida healer who blessed my hands that they might do good things. I quietly promised myself that they would.

  On the first day of Desert Storm in January 1991, television newscasts bristled with the luminescent green, night-vision images of ground targets on fire throughout Iraq. Buildings exploded from the attacks of cruise missiles and jet bombers. News reporters described the shock and awe as the air assault unfolded. I was on duty at the Finley Hospital in Dubuque, Iowa, and watched the news with the nurses in the break room. Charlene, who had been a young nurse during the Vietnam era, shook her head and said we didn’t need another war; then she walked away to attend her patients. One of the male nurses, an Army reservist, told us how the Air Force was going to kick ass. I said he was probably right and continued to watch with a mixture of disbelief and belief, wondering if Desert Storm would become another Vietnam.

  In the preceding months, I had received mass mailings from the National Guard advertising the benefits of military careers for doctors. They showed military doctors rappelling down mountainsides with medical equipment. Others showed combat hospitals, deployed trauma teams, medevac helicopters, and night-mission rescues. One of the brochures touted the virtues of a career in aviation medicine. It included training in the flight surgeon academy and promised a life of adventure. The gist of the messaging was that the military offered a medical practice that pushed boundaries. They were recruiting doctors with an eye toward living on the edge. As I read, I felt as if the military had wiretapped my thoughts and designed the brochures with exactly me in mind.

  —

  Following my post–medical school internship at the Marshfield Clinic in Wisconsin, our family had moved to Iowa, where I did an additional year of training at the University of Iowa Hospitals and then started my private practice in emergency medicine in 1990. I joined the emergency staff of Emergency Practice Associates and worked in several hospitals in Iowa’s larger cities, Des Moines, Dubuque, and Waterloo, and in smaller communities as the need arose. I scheduled as many as a dozen twenty-four-hour shifts a month and occasionally threw in a few twelve-hour shifts. That number of shifts bordered on excessive, but I scheduled them anyway because critical cases of trauma and cardiac resuscitation engaged me like nothing else. And when I wasn’t working my ER shifts, I taught advanced cardiac life support (ACLS) to other doctors in practice. Managing critical patients was my gift and I loved it and excelled at it. I became quick, decisive, and knowledgeable; I built a reputation in the larger hospitals as a “trauma dog.”

  Decisiveness and knowledge didn’t automatically translate into saving lives. Patients still died regardless of how fast I acted to stop their bleeding or correct their cardiac arrhythmias. And when they died, I often felt that just one more procedure or perhaps one more unit of blood or a final dose of medicine could have made a difference. When I called a code and pronounced the time of death, I felt like somebody had cheated me out of completing a thousand-piece puzzle by hiding the final critical pieces, except the enormity and emotional impact of an unsuccessful resuscitation felt infinitely greater than the momentary disappointment from a trivial game. Every patient who died in the ER reminded me of the omnipresent risk of mortality.

  The other aspect of treating critical patients was dealing with the aftermath of tragedy. After a case, I counseled families and tried to explain how their loved ones had died. I saw family members fall apart, physically and emotionally, as if suddenly ravaged by a Midwestern tornado. I wanted to stand nearby and buffer them from their storm of grief, but I could not. When they gathered themselves together to leave the hospital, I lifted their tragedy and carried it with me as if it belonged to me, because in fact it did.

  Despite the critical nature of emergency medicine, it had a rather mundane side. I frequently spent a majority of a shift diagnosing and treating common colds, minor cuts, bumps, and bruises, and doing preventive medicine. Quite a few patients came for nothing more than a medical work excuse. Minor fender-benders frequently clogged the ER. They required a “medical clearing” for insurance purposes, which, because of medical-legal issues, meant that a full gamut of X-rays and labs was ordered and a full exam documented. Those kinds of cases cut at the heart of the challenge and excitement in emergency medicine. They made me feel like my skills were being wasted. In any given month I accumulated cases that thrilled me and cases that bored me, and the boring cases abraded the entire ER experience. Some doctors left emergency medicine just for that reason. That was not an option for me. The Army and its opportunities seemed to offer a solution, especially to the vital connection to critical patients I needed so much.

  The day after Desert Storm began I phoned the medical recruiter of the Iowa National Guard and asked if they needed ER docs. The recruiter, Major James Regur, assured me they did and arranged to meet me the next day at the Country Kitchen restaurant in Iowa City. He arrived just a bit after noon, dressed in his class A army-green uniform. We settled into a corner booth. The first thing I noticed was that he spoke with a fast, clipped pattern, like that of a high-strung person, yet his body language gave the impression of one in control. Major Regur was older than I expected and much thinner. He had thinning hair, an overly large hearing aid, and thick glasses. I wondered if he had ever carried a rifle. His black briefcase was stuffed with medical corps brochures like the ones I had received in the mail. He handed me several and began to explain the needs of the Iowa National Guard. He discussed benefits like paid medical conferences and retirement after twenty years of service and stressed that I had to pass a medical and physical exam. I told him no problem. He also said I needed an age waiver because I exceeded the maximum age for commissioning and that the waiver might slow the application down a bit.

  “ER docs are in demand,” he said. “If you have no medical problems and can run two miles and do twenty push-ups, we can start the application process soon as you’re ready.”

  When I got home, I mentioned to Collin that I had started an initial discussion with the National Guard and that I was just looking at the “possibility” of joining. She stared me down and said it wasn’t a good idea, that I didn’t have the time, that it wasn’t a good fit.

  “Do you really need the military to do medicine?” she asked with just enough bite to make me defensive.

  “No, but it’s something I’ve always wanted.”

  She was disappointed that I hadn’t talked with her before contacting a recruiter. I assured her everything was only preliminary. “Preliminary” was a word I used when I wanted to nullify any impression of making major family decisions without involving my wife. She knew better. So did I, but I said it anyway, because doing so served the purpose of allowing us both to feel as if we were not jumping headlong into unexplored territory.

  By the time Major Regur had compiled all the various components of my application, Desert Storm was nearing an end, and I wound up deciding to put my application on hold. The major kept in touch and sent me information about special Army training and research opportunities in trauma and aviation medicine. I read the brochures several times. Every word and picture made military medicine seem so exciting, as if it were on the frontier of critical care and trauma research. Military doctors were a rare breed of doctor and that’s what I wanted to be. In contrast, practicing civilian em
ergency medicine had become stale and predictable.

  Collin knew my love-hate relationship with emergency medicine wore me down. Sometimes I would come home from a long shift and complain that I had done nothing but treat ear infections and colds and that I needed to work in a setting with more trauma. She had seen the Army recruiting brochures I left on the kitchen table, so when I told her in July 1992 that I wanted to explore the option of military medicine once more, she wasn’t totally surprised.

  “I know you’re not totally happy with the ER,” she said, after one of my shifts. “What are you thinking about the military?”

  “I just want other options. Relocating to a trauma center doesn’t seem realistic with our family.”

  “It’s not,” she responded.

  “I think the National Guard might provide a challenge.”

  “But why do you always need a challenge?”

  “I don’t,” I claimed, “but half my time is wasted in the ER. It’s not exactly what I wanted.”

  She continued to reiterate her concerns about me fitting into a military bureaucracy and about how it would impact my time with our family. Her concern was that at my age I would be a late starter and would always be answering to officers ten to fifteen years younger. She saw that as more significant than the age gap I had experienced in medical school and told me that I would always be fighting against it. I responded that I would always be the older, new doctor no matter where I worked and that it made no difference to me. I needed more challenges in medicine and short of relocating to a large city where I could work in a major trauma center, I felt the Guard was a good part-time option. Collin also wondered out loud about the issue of military rank and how I would accept being senior in age and junior in rank. Not an issue, I told her. It didn’t matter what issue she mentioned, I had an answer. Just short of exasperation, she told me to think about it hard before I did anything. I said I had.