The Doctor Will See You Now

by Cory Franklin

  The risk of head trauma in football will never be completely eliminated. Parents and young players must decide the level of acceptable risk, just as they do in other sports. But medicine, technology, sports, and common sense can converge with a common goal—to make sure football is not unsafe at any age.

  VIII

  CLINICAL VIGNETTES AND A HUMOROUS INTERLUDE

  63

  ELENA AND ANGELA

  * * *

  Well, I’m not the kind to live in the past

  the years run too short, and the days too fast.

  —AL STEWART, “TIME PASSAGES”

  RUMMAGING THROUGH MY DESK RECENTLY, I discovered a peeling old Polaroid photo taken before digital cameras were introduced, circa 1982. The picture shows a young Hispanic girl, no more than twenty, holding an infant, smiling for the camera with the old Cook County Hospital Intensive Care Unit as a backdrop. Printed in blue ballpoint on the back of the picture is “Gracias a todos, Elena.”

  I hadn’t thought of Elena in many years, but that long-forgotten picture reminded me of her story from decades ago. One morning, without warning, two residents looking for a bed for a patient suddenly wheeled the petite Elena into the intensive care unit (ICU) on a stretcher. She was in a coma, sweating profusely, barely breathing, with an extremely low blood pressure. The residents explained that she had a severe blood infection and, incidentally, was several months pregnant. Some attending consultants followed them in and confirmed that the patient had become ill very quickly on the ward; they were certain she was dying. When the nurses got her into bed, she was indeed near death.

  To save patients like Elena, the ICU team—nurses, physicians, therapists—must possess two things: a firm belief that the patient can be saved and, just as important, luck. We had the former; it was too early to tell whether we had the latter.

  I explained the grim situation to Elena’s uncle and grandmother, as the doctors placed a breathing tube and started infusing fluids, antibiotics, and medicine to raise Elena’s blood pressure. Her bedside nurse, Angela, a young African American woman not much older than Elena, was relatively new to the ICU. Angela was cheerful, always smiling, and anxious to learn, but she had never been in charge of a patient as sick as Elena. Now she approached her work with a steely resolve and a determined expression I had never seen before. If she was afraid, she didn’t show it. And there was certainly ample reason to be afraid for Elena’s life, which hung in the balance.

  Angela was invested in Elena’s care, so she took an extra shift to be with her. She made sure Elena had an experienced senior nurse to take over when her shift was finished. By the end of the day, Elena was still alive but was not much better. She might still be dead in an hour. I discussed the treatment plan with the overnight residents, but in truth there was little to do. Either Elena would respond to treatment for the infection or she would die.

  I went home with trepidation, but I secretly believed that Elena would pull through. I had no choice—for patients like Elena, pessimism can be a mortal enemy.

  The next morning, Elena was still alive and beginning to improve. Angela was taking care of her again. On rounds Angela knew every lab value and every trend in the vital signs better than anyone. When I asked her if Elena had improved enough for us to reduce her life support medications, Angela looked me squarely in the eye and said, “No, not yet. But by this afternoon.” I thought to myself she did not have the experience to answer so confidently, but she turned out to be right.

  Meanwhile luck, or providence, was on Elena’s side, and she survived. Four days later, when her breathing tube was removed, the first thing she asked about was her baby. Would it survive? We told her she would be transferred to the gynecology ward, where they would know better. Then she thanked everyone in Spanish. She did not speak English, but she realized how close she had come to dying. Before being transferred, she made a point of kissing Angela’s hand.

  When I asked Angela how it felt, she said, “Real good. As good as any kiss I ever got.” Elena went off to gynecology, and we lost track of her. We heard later she delivered a baby girl, premature but healthy. About six months after that, Elena returned to the ICU with her daughter and posed for the picture I found in my desk. Her visit was a real morale boost for the nursing staff after a particularly rough couple of weeks caring for sick patients. After that I made a point of asking former patients to visit the ICU so everyone could see them when they regained their health. That should be part of the protocol in every ICU.

  Unfortunately, Angela was off that day, and she never saw Elena again. That’s the nature of intensive care—intense emotional commitment and then separation forever. But Elena’s case became a turning point in Angela’s training.

  Over thirty-five years have passed. The peeling Polaroid photo is like a never-completed jigsaw puzzle. The Cook County ICU where this happened has been gone for more than a quarter of a century now; the building, knocked down and paved over, is a parking lot today. Elena would now be nearing sixty years old, and her little girl would be over thirty, perhaps with children of her own. It’s hard to imagine the smiling young woman in that picture as a grandmother. After a couple years, Angela left nursing to take care of her own children.

  For a brief moment, Elena, Angela, and I all lived together intimately in a world that has vanished. Now we are separated forever, with that peeling Polaroid the last evidence that world ever existed.

  64

  AN UNUSUAL SIDE EFFECT OF MY MEDICINE:

  I CAN’T REMEMBER MY LINES

  * * *

  All substances are poisonous, there is none which is not a poison.

  —PARACELSUS

  DEAN PETER RICHARDS of London’s St. Mary’s Medical School was a world-renowned expert in teaching medical students to become doctors. One of his key counsels was, “All doctors must continue to learn, and not only about new advances but to appreciate the limitations of all knowledge.”

  Sage advice, not only for medical students but for us doddering old codger physicians as well.

  I learned, or relearned, that valuable lesson recently. A neighbor suffered a sports injury that resulted in an inflamed ankle. He visited his personal doctor, an experienced physician, who prescribed a seven-day course of corticosteroid medication to suppress the inflammation. The neighbor was a stage actor, and, after three days of taking the drug, he called me from his car on his way to a local theater for that evening’s performance. The reason for his call was that he suddenly realized he could not remember the precise location of the theater. He was familiar with the area and knew he was in the right neighborhood, but he was just not sure exactly where the theater was even though he had rehearsed and performed there for weeks. What was worse was that while he drove around looking for the theater, he also realized that he could not remember the lines he was supposed to deliver that night—the greatest fear of every actor.

  I was afraid he might be having a stroke and I inquired about other symptoms, but he had none. His only complaint was the loss of short-term recall. As he described his problem, I was struck by how calm he sounded considering that he was due to go onstage in an hour. Eventually the GPS in his car guided him to the theater, but this did him little good since he was still unable to recite his lines. The director was forced to cancel the performance, but fortunately it was a slow weeknight for ticket sales, and refunds were not a problem.

  On his way home, aided by his GPS, he called me back, wondering if he was experiencing a possible side effect of the corticosteroids. A neurologist might have been familiar with the answer to that question, but I was not, despite having prescribed corticosteroids for hundreds of patients. After consulting the Internet and my Physicians’ Desk Reference, I ascertained that corticosteroids could indeed cause impaired short-term recall. The drug can disrupt the delicate neural connections in the hippocampus, one of the regions of the brain responsible for memory. What results is damage to what one British writer termed “the fragile mental alch
emy on which we all rely.”

  Loss of short-term recall is not a frequently reported complication of corticosteroids, and some doctors, like me, may be unaware of it. Since so many patients take corticosteroids (prednisone is the derivative most commonly prescribed for a wide host of conditions), it follows that patients, in turn, may be unaware that short-term memory loss could happen to them after their doctors prescribe the medication.

  I advised my neighbor to call his physician and in the interim to stop taking the medication, read his lines over again, and get some sleep. Many actors find that sleep reinforces memory when they are attempting to learn chunks of dialogue. Fortunately, in his case the complication was reversible, and he was back onstage and able to deliver his lines for his weekend performances.

  This vignette was a lesson in many ways. All medications have side effects, and even commonly used medications have unexpected complications. Moreover, those complications have different implications depending on the patient. For an actor, loss of short-term memory is devastating. If the same thing happened to an elderly patient in a nursing home, it might have never been noticed. Even worse, it might simply have been written off to old age.

  That is why it is so important to listen to what your patients tell you and make every effort to understand their particular situations. One of the other pieces of advice Dean Richards gave to medical students was that doctors “also need to learn humility, in the face of their imperfect understanding and their patients’ courage.” When my neighbor could not remember his lines as a result of his medication, he did not panic. Rather, he exhibited composure and poise. Exactly the type of courage the great educator was referring to.

  65

  TWENTY-FIRST-CENTURY MEDICINE, OR “MOM,

  I WANT TO BE A DOCTOR”

  * * *

  Man. Woman. Birth. Death. Infinity.

  —DR. ZORBA (SAM JAFFE), OPENING FROM THE BEN CASEY TELEVISION SHOW

  SCENE: FAMILY DINNER TABLE, a middle-aged couple and their son, home from college.

  Father: “So, boy, have you figured out what you want to do with your life?”

  Son: “Yes, Dad, I’ve talked to my counselor, and I want to become a doctor.”

  At that moment Mother swells visibly with pride and says, “I knew it. Oh, son you’ll make such a wonderful doctor. Maybe you can open up your own practice.”

  Son demurs politely, “No, Mom. Once I finish my training, I plan on becoming part of an accountable care organization. You understand, financial and clinical risk means it’s essential to have the infrastructure to coordinate interactive team-based care. It’s all about being market competitive and empowering synergistic group and management service organizations that feature mutual arrangements on optimal practice management, health information technology, group purchasing, billing/collections, human resources, and other mission-critical functions.”

  Mother stares at him blankly.

  “Son, Dr. Kildare and Marcus Welby never talked that way.”

  Son stares at Mother blankly, unfamiliar with who these people are and what they have to do with medicine.

  Father chimes in, offering what he hopes is a more contemporary reference, “Don’t you want to be like that TV doctor, Dr. House, and make all those great diagnoses?”

  “House? Are you kidding? He was a terrible physician. His style was completely dysfunctional within the parameters of a hospital environment, and he had no concept of teamwork or care coordination. Plus his show got cancelled.”

  Father stares at him blankly.

  Mother, holding out hope, comes back, “Maybe you could be a surgeon like Ben Casey?”

  Son with another blank stare at Mother.

  “Who’s Ben Casey?”

  “He was the best surgeon on television. All night he’d be up doing a heart operation and then they would bring in some poor little boy and Ben Casey would single-handedly save him with an emergency appendectomy.”

  “Mom, it doesn’t work like that anymore. People don’t stay up all night and then operate. They have work limits now. I heard some surgeons talking on NPR, and it’s a revolutionary paradigm trying to make surgical hours ‘family friendly.’ And this business about this cowboy Casey single-handedly saving the little boy? Don’t you understand there are dozens of people interfacing in that boy’s surgery? Surgeons aren’t heroes anymore. Anyway, they are programming robots to do surgery. Soon robots will do appendectomies.”

  Mother, a little disappointed, struggles for words, “Well, I remember when that nice Dr. Green took out my gall bladder. I liked him.”

  A subtle eye-roll from Son.

  Father chimes in again slightly irritated, “When you become a doctor, you are going to take care of patients, aren’t you?”

  “Dad, it’s not really taking care of patients, it’s interfacing with clients. Medicine is about developing mutually beneficial models that focus on shared decision-making. The idea that your doctor is the expert who knows what’s best is the problem with medicine. The future is in creating guidelines and algorithms based on an evidence-based approach. The goal of medicine should be to standardize, so clients can be managed through clinical pathways facilitated by lower-cost providers.”

  Son grows animated, excitement in his eyes, “Don’t you see, Dad? You wouldn’t even need a doctor for most cases. My future could be in developing new algorithms for cases that don’t conform to traditional guidelines! And I could devise new checklists. Checklists are a revolutionary approach to medicine.”

  Father, slightly taken aback, doesn’t know what to say, so he says the first thing to come to mind, “Does that mean you won’t carry a stethoscope?”

  Another eye-roll from Son, this time not so subtle. “Portable ultrasound, Dad. Portable ultrasound. No more stethoscopes.”

  Father stares at him blankly.

  Mother asks, “I just want to know if you will still be helping people and making them better.”

  “Sure, Mom. What you are talking about is outcomes. Don’t forget I will be interfacing with the electronic health record, and it provides an industrialization function that enables us to process efficiency. Not only that, but the retrieval of clinical decisions, as well as cost and quality assessment, allows for iterative improvement. Do you have any idea what that means for outcomes?”

  Mother says nothing but nods with a wan smile and offers dessert.

  Son puts down his napkin and says, “Mom, Dad. I’d really love to stay and chat some more, but I have to run. I’m going to a lecture on how medicine needs to become more like the Cheesecake Factory—you know customized approach, more standardization, and enhanced quality control. That is so twenty-first century!”

  Son leaves. Mother and Father finish their meals. A few moments of awkward silence until Mother asks, “Oh dear, aren’t you proud of our boy?”

  “I guess. But there seems to be a lot of mumbo jumbo in medicine today. I sort of wish he’d go into something with a little less double-talk attached to it.”

  “Like what?”

  “I don’t know. Maybe politics. Pass the ice cream.”

  66

  A GUIDE TO HEALTH CARE POLICY—WITH APOLOGIES TO MORT SAHL

  * * *

  Liberals feel unworthy of their possessions.

  Conservatives feel they deserve everything they’ve stolen.

  —MORT SAHL

  IN THE LATE 1950s and early 1960s, there was no more acute observer of the American political scene than satirist Mort Sahl. In the tradition of humorists like Mark Twain and Will Rogers, Sahl played no favorites; by skewering Republicans and Democrats with equal aplomb, he was the forerunner to today’s political satirists, including Stephen Colbert and Jon Stewart.

  At the height of the Vietnam War in 1967, Sahl created a satiric monologue describing the three basic political factions in the United States, the left wing, the right wing, and the moderates. In turn he further subdivided each of those three factions into three wings, left, center,
and right, creating nine divisions in all, so the political spectrum looked like this:

  Left Wing: left, center, right

  Moderates: left, center, right

  Right Wing: left, center, right

  To illustrate his point, Sahl was able to categorize anybody’s political philosophy simply by examining their stance on the Vietnam War. For example, the “left–left wing” position was that the United States should unconditionally withdraw from Vietnam (which became the official American position five years later). The “center-moderate” position was “we should stay because the Communists may strike somewhere else in the world” while the “right–right wing” position was that we should immediately start bombing not only Vietnam but Communist China as well.

  Since then little has changed—the political divisions remain. Today’s left wing reads the Daily Kos blog and the Huffington Post, watches MSNBC, considers Rachel Maddow their spokesman, and longs for the pre-Trump days of Barack Obama.

  Sahl’s right wing, now known as conservatives, reads the National Review, watches Fox News, reveres Rush Limbaugh as their spokesman, and anticipates the coronation of Donald Trump as king.

  Moderates are currently searching for something to read, because the only middle-of-the-road publications left standing are People magazine and Car and Driver. Virtually everything else has folded or has become a house organ of either the Left or Right. Moderates have no official spokesman. They are reduced to watching reruns of Cheers and Frazier while they pine for the days of Johnny Carson and his apolitical monologues.