“Hang two units of O negative,” the attending said. Somebody ran out to get blood for a transfusion.
“Peripheral pulses not palpable,” a nurse said. Her blood pressure had dropped so low that we couldn’t feel her pulse in her arms or legs.
“I can’t get a line in,” the intern said.
“I’m trying on the other side, no access,” the resident said. The woman was still breathing on her own, but nobody could manage to get an IV into her veins. Her veins were collapsing as she bled out into her own abdomen, and the IV just wouldn’t go in.
“I’m going for a femoral stick,” the resident said.
“Let’s get to the OR,” the attending said.
“Who are you?” a nurse said. And in that moment the attention in the trauma bay swung from the patient to a thin woman standing by the door, holding a purse. “Are you her family?” the nurse asked.
“No,” the woman said. And I was quietly grateful, because I would not want this cutting off of clothes or digging for veins to be witnessed by our patient’s child. “I’m the social worker. Her family is in the emergency room, and they want you to know she’s DNR.”
The tension in the trauma bay slackened. DNR means “Do not resuscitate.” It meant, in this case, that we would not be going to the operating room. We would not slice this eighty-four-year-old woman’s belly open to find and stop the bleeding inside, or transfer her to the ICU with a tube down her throat. It meant that, if she was dying, she was going to die.
Then the strangest thing happened. Most of the trauma team just wandered away. The social worker stayed, watching, in a corner of the room. The attending and the intern stayed, too. It was just the four of us, and we were all quiet. I watched as they tried over and over again to get an IV into her veins to transfuse blood. They went for the femoral vein, a big vein on the inside of the hip. And no luck. They tried using the ultrasound, and cutting open her leg to expose a vein. They were still digging around in her veins, cursing quietly, when the heart monitor began to slow.
“No chest compressions?” the intern asked.
“No,” the attending said.
And then the lady started to die. She just bled out right there in the trauma bay, with two doctors poking uselessly at her collapsing veins. I couldn’t believe it. You don’t just die, in the hospital like that, from something so simple as bleeding. Right? You don’t just die because we can’t get a needle into your vein?
“All right, that’s it,” the attending said. And then everybody put down their instruments, tore off their yellow gowns, and walked away. The heart monitor was still beeping, but more and more slowly. I went to the door of the trauma bay and stood next to the intern. He seemed to think there was nothing more for us to do, so I also did nothing. He and the attending started talking about another case scheduled in the operating room, and the beeping of the heart monitor got even slower and less regular.
I knew that the woman was dying. Should I hold her hand? I thought. Should I comfort her? But I didn’t. I stood silently with the rest of my team, thinking I would learn from them to do what a doctor does when someone dies.
The lesson I learned that day was that a doctor’s work is done when there are no more interventions to do. We stood, speaking lightly of other things, in the door of the trauma bay. The only thing that marked our patient’s death was the long slowing, and stopping, of the heart monitor’s beep. Finally, our patient lay alone, naked, dead on the emergency room bed. She was eighty-four years old. This whole time, nobody had spoken her name. That’s it? I thought. That’s it?
The social worker came in and covered the body. She drew the curtains on the trauma bay so we could no longer see in. She must have cleaned up the body and the bay, because a few minutes later I saw her leading a middle-aged man and woman into the room. The woman clutched the man’s arm, and drew her breath in sharply as the social worker pulled the curtain aside for them to step into the room where our patient’s body lay.
I stood in the noisy ER hallway, barely hearing as the intern joked with a nurse. This was the first patient I had seen die. Guilt washed over me: I was only a medical student, but I was also a twenty-eight-year-old woman. I had loved my grandmothers. I knew better than to step away and let an elderly woman die alone.
I could have walked away from my team and to her bedside, and held her hand as she passed. I could have done anything at all. But I didn’t. I just played the role I was being taught, instead of acting like a decent human being.
I WAS STILL FEELING SHAKEN as I hurried away from the ER, but there was no time to really calm myself. I was scheduled to assist on a lumpectomy in the operating room. I had not met the patient yet; I just knew that she had breast cancer and that we were doing a surgery to remove the cancer.
I rushed into the OR changing room, ditched my white coat again and slipped on a scrub hat, mask, and booties. My patient had already been brought back to the operating room, which meant that I was committing the cardinal medical student sin of being late to a surgery. I had missed my chance to place a catheter or help the anesthesiologist put a breathing tube down her throat. At this point I could not be helpful, but rather a distraction and an irritation to the surgical team.
As I scrubbed my hands and arms, I frantically reviewed what I knew about breast cancer. The attending was going to ask me questions, and I had not had time to review before the surgery. Tumor, nodes, metastases, I thought. A mastectomy followed by chemotherapy and radiation. Routine breast self-exam is no longer recommended by the American College of Obstetricians and Gynecologists. Most patients diagnosed with this disease will ultimately die of it, even if they go into remission. Five-year survival rates of . . .
I finished scrubbing and backed into the operating room as quietly as I could. As the door swung open, the surgeon glanced at me. I could feel her irritation. Any intrusion into the operating room is not only a distraction but also a potential source of contamination. Would the air blowing over our patient’s body from the open door carry germs that would cause an infection? Would I de-sterilize something? The surgeon’s brow furrowed, but her mouth was covered by the mask.
I walked over to the scrub nurse, who quickly gowned me and watched carefully as I put on my own gloves. My back was to the patient. I opened the sterile gloves and lay them inside their sterile paper packaging. I managed to get one glove halfway on, but fumbled with the second.
“Do it again, they’re contaminated,” the nurse said.
I cursed silently and then opened another pair of gloves. This time I managed to slip them over my hands in the proper fashion, without touching the outside of either glove with my hand. I was sterile and gowned.
I turned to join the operation, and that’s when I saw our patient. She was not older than me.
She lay perfectly silent and perfectly still as the light poured down over her. Underneath the blue sterile drapes, I could see the side of one of her legs exposed in the light. It had the firm lean muscles of a bicycle commuter and, curving up her leg from the outside of her knee almost to her hip was a tattoo of a bird. An egret, I think.
I stood in that quiet space while the surgeon worked on her, quickly cutting through skin and dissecting down to her breast tissue. She removed a lump of breast, put one stitch in the top of the lump and one on the right so we could tell which side had been facing up inside the patient, and placed it in a sterile tray to be examined by the pathologist. If the margins were clear—that is, if no cancer cells were found at the edges of the lump—this young woman would go on through the rest of her treatment, and eventually have her breast reconstructed by another surgeon.
And yet she would likely die of it, soon or eventually. I knew that. I had memorized that fact. Did she know, or did she want to know? I imagined her bicycling along the same route I took to the hospital, how her legs would flash in the sunshine for as long as she was as young and as alive as I was. The surgeon closed the wound with tiny stitches that ran up the edge of ou
r patient’s chest. I kept my folded hands to myself, and helped clean up when the surgery was over.
CHAPTER 13
I SAW DAMIEN’S X-RAY BEFORE I MET HIM. IN THE EMERGENCY room hallway, looking at the computer screen that showed the results of his X-ray, he was just another diabetic foot. “What do you see?” my resident asked me.
“Osteomyelitis,” I said. “There,” pointing at a shadowy spot in the middle of the foot, where infection was eating away at the bone.
“Good,” she said. It was unusual to get more than four or five words at a time out of a surgeon. I stared at the X-ray and kept quiet. At that time, I didn’t mind that the surgeons didn’t talk to us students or try to get to know us. They could be scary—I had seen several of them scream—and it seemed like we students were safer if the surgeons didn’t know anything about us, anyway. Later, I would be on teams where I would be truly included in patient care and able to contribute, and I would realize how strange and dehumanizing the surgery experience was. But at the time, it was all I knew of the wards.
This was my next-to-last night of trauma call. By then, I’d seen several patients with osteomyelitis of the foot, and scrubbed in to help with their amputations. Folks with diabetes get these infections for a lot of reasons. Diabetes harms your immune system, making it harder for your body to fight back simple infections. It also attacks the nerves, starting with the small nerves out at the far end of your body. Feet start to tingle, then hurt, and then they go totally numb. This makes you prone to foot injuries, because you stumble, and then you may not notice an injury. If I cut the bottom of my foot, I’d know immediately. But with bad diabetes, a little injury to the toe can go unnoticed until it blows up into a big infection. That’s what we call a “diabetic foot.” When antibiotics fail—as they often do in cases of diabetic bone infection, because of the already weakened immune system—surgery is the only option.
At St. Vincent’s, I had learned how good primary care can prevent these amputations. We would teach our diabetic patients to check their feet every day. When they come into the clinic, we look for foot injuries, then check the reflexes and sensation in the foot to see how the nerves are doing. It’s part of the standard of care for diabetes.
“Sheesh,” said my resident. “He’s already had one amputation.” She was looking down at his chart, where the emergency room doctors had written his history. “You’d think this kid would’ve learned his lesson.”
This kid? I thought, and looked down at the chart. Damien was twenty-one.
The other amputations I’d seen had all been in older people. There was an eighty-year-old transferred from a nursing home, and a fifty-five-year-old severely obese woman, and an immigrant in his sixties. All these people had had diabetes for many years, and they were uninsured in Texas. They weren’t getting good primary care.
But why would a twenty-one-year-old already be getting his second amputation? Damien had had diabetes since childhood, but even so, it was unusual for the disease to be so devastating at such a young age. “Let’s go talk to him,” the resident said.
There’s a lot of variation in the quality of rooms in our county ER, and this was not a nice one. The worst “rooms” are just ten-by-eight spaces where one moaning person is separated from the next by curtains. This one had actual walls, but no windows, and was very small. The kid was on a gurney, and he didn’t turn to look at us when we came in.
The resident sat by the bed. “Damien,” she said gently. He turned and looked at her. “I’m Dr. Sklar.”
“You the surgeon?”
“I am.”
“You going to cut off my foot?”
The resident looked down. This was, of course, the news we had come to deliver. But she wanted it to come more gently. The kid already knew. “Well,” she said, “we need to do surgery.”
“Oh no, no, no.” He tossed his head back and looked at the wall behind him. “Don’t you fucking do that,” he said. His voice dropped down to a whisper. “Please don’t do that.”
“I’m going to try,” the resident said, “to take as little as possible.” She reached down and touched the top of his foot, above where the infection was. “It looks like your bones are infected up to about here,” she said, “so I’m going to try to leave the back half of your foot.”
“Please,” he said.
“I know this is awful.”
Damien half rolled over, turning his back to us. “You don’t know shit,” he whispered.
THERE WERE, I LEARNED, a lot of reasons why a twenty-one-year-old would already be needing his second amputation. Damien was from Chicago. He was diagnosed with diabetes when he was eight years old. Childhood diabetes is relentless: the pancreas gets totally destroyed, so those kids need insulin every day for their entire lives. They need special diets and regular medical checkups, attention from nutritionists and social workers: a whole, organized, medical team. The family also has to organize itself around taking care of these kids, or else they get bad complications, from infections to coma to early-onset heart disease. Even in the best situations, bad things happen. A friend of mine from a wealthy family, who was a doctor himself, had chronic blackouts from central nervous system complications from his childhood diabetes.
Damien’s family couldn’t organize itself around caring for him. His dad had been in jail Damien’s whole life, and he and his mother and sisters were chronically homeless. He dropped out of school, and had been arrested three times by his eighteenth birthday. He’d ended up in Texas just three months before, coming down to live with a friend. But when the friend lost his apartment, Damien was on the streets again—without insulin. This was not the kind of life that lends itself to the diligent care required to manage diabetes.
Even if Damien had had great access to medical care, there is reason to think that he might not have received the best care. In 2003, partly in response to studies from the 1990s showing that black and Latino patients were less likely to be given adequate analgesia—pain medication—in emergency rooms, the Institute of Medicine (IOM) undertook a major review of racial bias in medical care.*What they found was disturbing: not only was racial bias prevalent across medicine but bias by physicians contributed independently to the earlier deaths of African American men. The studies that the IOM report considered controlled for factors such as socioeconomic status and access to care, and showed that race alone often affects the quality of care patients receive. For example, National Institutes of Health (NIH) researchers found that black veterans treated for their diabetes at Veterans Affairs hospitals were less likely than white veterans to get basic standard-of-care tests like an eye exam—which is particularly important because diabetes can cause blindness. Discouragingly, another 2014 study found that even in a patient-centered medical home run out of an academic medical center in Washington state—which should offer topflight primary care—black diabetes patients got worse care. Doctors were less likely to do eye exams on their black patients, less likely to vaccinate black patients for the flu, and even less likely to check their hemoglobin A1c (a standard test that tells us how the blood sugar has been running on average for the past three months). Black patients in the study population also had higher average blood sugars than whites—placing them at an increased risk for complications like the infection Damien had. The research on this topic goes on and on.
John Dovidio, a sociologist who studies race in medicine, argues that many physicians exhibit “aversive racism.” He means that we value equality and condemn the notion that we might be racist, but we still act on subtle, unacknowledged bias. Patients pick up on aversive racism through cues, such as shifty eye movements or the physician leaving the room quickly. And leaving the room quickly is a problem: the shorter doctor visits that patients of color receive may explain why doctors are less likely to hit the standard of care for these patients. Researchers have also examined factors among physicians that contribute to bias, and the results are incomplete, but interesting: physician-patient teams
of the same race are less likely to be influenced by bias. This is one reason why it’s vitally important to educate a diverse population of doctors.
To evaluate whether physicians have unconscious biases, researchers use a tool called the Implicit Association Test (IAT). This test is available online, and anyone can take it. I did myself, and I got the most troubling possible score: my answers showed that I have a strong automatic preference for European Americans as opposed to African Americans. About 27 percent of people in general had gotten this result at the time I took the study, and 27 percent more showed “moderate” preference for European Americans as opposed to African Americans. Sixteen percent had a slight automatic preference, 17 percent showed no preference, and the other 12 percent had slight to strong automatic preference for African Americans. Most white respondents preferred whites, and so did about 50 percent of African American respondents.
My result was, obviously, disturbing. I’d like to think that I’m not that shifty-eyed doctor who rushes out of the room. I trained in an African American community center, have an excellent African American academic mentor, and I’ve thought about these problems a lot—surely I shouldn’t be that biased!
I repeated the test, and got the same result.
This was discouraging. If I’m so biased, could I ever be a good provider for nonwhite patients? Maybe I should just stop trying. My presence in a medical encounter with an African American patient could actually be harmful.
Fleeing from these problems, of course, is not really an option for physicians—and, given how few African American and Latino physicians the medical system trains, it would be disastrous for patients. White docs cannot responsibly wait for a revolution in medical education so that our colleagues of color can “fix” this problem; nor should this issue be the sole purview of physicians of color. We all have to take good care of our patients now. So researchers have come up with some ways that physicians can begin to address bias in our practices.
No Apparent Distress Page 13