Monday, December 2, 2013
“I’ve braved the rain and sleet and snow and have returned for another exciting shift here at the fabled ‘Night Clinic’,” I announced as I shook the snow and slush from my boots. “Maybe the bad weather will keep it quiet.”
“Don’t hold your breath; all the exam rooms are full and five more waiting,” Miss James reported. “You can start with the swollen ankle in one.”
Her voice was cold with more than a touch of annoyance.
What did I do now? I put my dirty clothes in the laundry, washed the dishes, put the toilet seat down, let her…
“Miss James,” I began, “have I done something to upset you?” I did my best to feign contriteness.
“The time is 7:30. Our shift starts at seven. Why are you always late?”
“Well, today I had to…”
She just walked away, not really interested in an answer to what I now surmised was a purely rhetorical question. Her point made, we went to work.
“Gregory Jackson, ankle injury playing basketball; nineteen, lives on Maple, unemployed,” the chart reported.
I knocked twice and then went in and saw a very tall, thin young man with his ankle elevated and swathed in an ice pack.
“Good evening, Mr. Jackson, what happened to you?”
“Well, Doc, I was driving to the hoop and was about to do my Dr. J, you know fly under, up and over the hoop to slam it home when this little guy, Bennie, I think is his name, undercuts me. I landed right on my ankle and then it swelled it almost the size of the ball. The other guys almost had to carry me here.”
I pulled off the ice pack and then looked at the X-rays which were already pulled up on the screen. I blew them up as big as I could.
Soft tissue swelling, separation of the joint, nothing broken.
I looked more closely at the ankle which was very swollen and had a slight purple hue. When I tried to move it my patient winced in pain.
“It looks like you have a very bad sprain, Mr. Jackson. I’ll wrap it up for you, but you need to keep it iced down for at least the next twenty four hours and stay off if for about two weeks. I’ll give you the number to the Ortho clinic at the University Hospital, call or go there to make an appointment to be seen next week, OK?”
“Got it, Doc. Oh, by the way, can you get me the number or address for Medusa?”
“I saw her go into one of your exam rooms, this chick we call Medusa. We see her around all the time, but she won’t talk to anyone. But, she’s one hot chick. Every guy I know wants to get ‘in’ with her, if you get my drift.”
“Sorry, you’re out of luck. You’ll just have to do that on your own. Just check out with Miss James at the desk. She’ll have all the instructions and the number to call for follow up written down for you.”
I went on to room two, but I did glance at the chart for room three. Sure enough the name was Medusa , while the rest of the chart was blank. First, however, there was abdominal pain in two.
I glanced at the name, Rufus T. Horsefly, fifty five, abdominal pain for two days.
“Good evening, Mr. Horsefly. I’m Dr. Barnes,” I began, trying not to betray my desire to dispatch him and his abdominal pain as quickly as possible so that I could move on to this mysterious Medusa. “What is the problem you’re having?”
“Hello, Dr. Barnes,” he answered as I sat down across from him. “I’ve had this pain in my stomach and back for two days.”
“How did it start?” I asked, trying not to look too bored.
“It started in my back then moved to the front. Today I had some numbness in my legs and I almost passed out. I figured I better get it checked out, you know, better safe than sorry.”
I was actually beginning to get worried at this point and, as it turned out, with good reason. I quickly gathered the rest of his history: untreated hypertension, cigarette smoking, some alcohol use, father died suddenly at age sixty.
“Let me check you now,” I requested/commanded. He lay down on the exam table and I felt his abdomen. He cringed slightly as I palpated all over his abdomen, particularly just above his umbilicus as I felt what I feared, the prominent thump, thump, thump of what I presumed was an abdominal aortic aneurysm. I felt his femoral pulses, which were only barely palpable, while his carotid and radial pulses were strong. I looked at the chart again, recorded blood pressure was 180/95, heart rate was sixty.
“Miss James, call 911 please and request an ambulance,” I called out to her at the front desk. I started an IV on Mr. Horsefly and drew some tubes of blood to go with him for a type and cross and lab.
“Mr. Horsefly,” I started to explain, “you almost certainly have an abdominal aortic aneurysm, either expanding or already ruptured. This is a very serious condition, one which is life threatening. An ambulance is on the way to take you to the hospital where you will need some sort of surgery. Do you understand?”
The look on his face told me everything as his light hearted countenance was replaced by fear.
“I’m going to call the hospital and ask that Dr. Singer be standing by; he’s the best vascular surgeon around, OK?”
He nodded his head and I left the room. Luckily, Dr. Singer was available and I was able to speak to him directly. The ambulance arrived and Mr. Horsefly was wheeled out to the waiting vehicle, lights flashing in the snow, siren ready to sing.
As he was leaving, I had to lighten the moment a bit, “Mr. Horsefly, by the way. In the movie Duck Soup, Groucho’s name is Rufus T. Firefly, not Horsefly.”
Mr. Horsefly smiled as they were loading him into the ambulance.
“I know, ‘the horseflies were on the Firefly’s and the Firefly’s were on the Mayflower,’” were his parting words as they loaded him in the back. I made a mental note to check on him the next day.
Back to the grind, and Medusa.
I knocked on the door and entered room three.
“Good evening Miss…” I started my usual introduction but stopped when I saw the young woman waiting inside.
She was sitting on the chair, dressed in a very thin coat, her legs were bare and she had her arms wrapped around her chest. She wore ragged boots with a hole in the bottom. She had long black hair with a white bandana and her skin was the color of chocolate mousse, smooth and silky. Her eyes, those eyes were the most amazing eyes I’d ever seen, dark brown with long lashes. All in all, even as dirty and disheveled as she was she was an amazing, striking beauty. I caught myself and started my introduction again.
“Miss Medusa, I am Dr. Barnes. What is the problem that brings you in here tonight?”
“Cold,” was all she said.
I was caught a bit off guard by the brevity of her answer. “Excuse me, did you say that you have a cold?” I asked.
“No, I was cold and needed a place to warm up,” her voice was as silky smooth as her skin and there was an aura about her which beckoned to draw me into her world. I had to stop myself and even shake my head to return my focus to medicine.
“I’m sorry, but this clinic is for those who are sick or injured. I know it’s unusually cold tonight and wet and dreary, but there are other places you can go. There are shelters and there is the mission over on Fourteenth Street.”
“I can’t go to those places. Bad things happen to me. Oh, why did I ever come to this place and time. I never should have been so trusting.”
Her words started to pique my interest. “Place and time?” She certainly was not the Medusa known from mythology. No snakes for hair or gnarly face and teeth. Indeed, she was the complete opposite. There was great beauty which radiated from her and filled the room and that aura, a remarkable feeling which emanated from her soul, reached out and touched me. She did seem to be in some sort of trouble, but a chief complaint of “cold” did not require my medical services. However, the profound sense of sadness which surrounded her, as well as the inexplicable attraction I was beginning to feel overwhelmed any necessity to follow the book.
“We are sort of busy, but you can stay in our little break room for a little while. You can warm up and I’ll see if we can find a better place for you to go.”
Maybe my apartment. No,no, don’t forget Miss James.
“Thank you,” she replied.
I led her to the back of the clinic, got her a cup of coffee and a blanket.
“Tea please, if it’s not too much trouble,” she requested, but to me it seemed to be more than a simple request. I fixed her a cup of tea, English Breakfast, from the supply that Miss James kept and started to go back to work, but I almost couldn’t drag myself away from her. Finally, the slightly irritated voice of Miss James snapped me back to reality.
“Dr. Barnes, patients are ready in rooms one, two, three and four and the waiting room is full.”
I felt a jolt back to reality.
“I must go,” I said to Medusa, “but I will come back and check on you when I can.”
“Thank you, Doctor,” she replied, clutching the mug of tea tightly in two hands,
I picked up the chart for room one, Mo Smith, lacerated arm. I knocked on the door and went in to find Mr. Smith sprawled out on the table, a towel soaked in covering his left arm.
“Good Evening Mr. Smith, what happened …”
And so it went room one, then two, then three, four, back to one and on and on, diarrhea, fever, back pain, headache, belly pain, broken ankle, broken arm, broken hand until it was four a.m.
“Just one more patient, Dr. Barnes, waiting in room two,” Miss James reported. “A Mr. Persy, sore neck.”
“Thank you, Nurse. I think I’ve earned my money tonight. How many patients have I seen?”
“Forty eight. Mr. Persy will make forty nine. I think that’s a record. The cold weather brings them in, I think,” She concluded.
I knocked on room two and went inside.
“Good morning, Mr. Persy. I’m Dr. Barnes. What is the problem you are having?”
“Is she here?”
“Is who here?”
“Medusa. I’ve been searching for her for quite a while.”
What does HIPAA say?
“I’m sorry Mr. Persy, but I do not know any ‘Medusa’ and if I did and she was a patient I would not be allowed to tell you; rules you know.”
I wasn’t sure why I didn’t give him some intimation that I had at least seen her. Technically, she had not been a patient, just cold and all I had treated her with was a cup of tea. I tried to learn more.
“Maybe, if you could tell me something about her I could help you. She may have passed through here under an assumed name. It has been known to happen before. After all, we are here to help people who are ill or injured. All we want to do is make them better. Most of the time we don’t care if the name is real.”
He scratched his head and then stroked his chin.
“OK, let me tell you about her. Medusa was born in what would be modern day Turkey, a long time ago. Nothing is known about her parents, but she had two sisters, both of whom are dead. They were all hideously ugly and the two sisters pined away, wishing to be beautiful, like Medusa. Medusa, however, was a real beauty, but this beauty was more of a curse.
“She is most beautiful,” I blurted out, before I realized I’d blown her cover.
Mr. Persy smiled before he continued. “As I stated, she was a beauty. But, Medusa, ah Medusa, she was always lost in thought. She could read and write and could remember every little detail of everything she had ever seen, heard, or done. And, more than anything, she was wise. From the time she was twelve people came to her for advice.
“Kings would come and ask if they should go to war or surrender. Men would ask about marrying, women would ask if they should accept proposals. When was the best time to plant, if the rains would be coming and on and on. And, she was not clairvoyant, just wise. She had a way of sifting through a mountain of information and distilling it down to its essentials and then rendering precise and accurate judgment. This was a gift from the gods. Being human she could not help but boast. She was reported to have said she was wiser than Zeus and Athena.”
“Wait,” I interjected, “are you telling me that she has been around for thousands of years. That the Medusa who is or was sitting in my little break room, drinking tea and wrapped in one of my blankets is the same Medusa from Greek mythology?”
“Yes,” was his terse reply, “but she is far different from the beast depicted in the mythology.”
“That is for sure,” I answered, “but, I should not have interrupted. Please go on with your story.”
“Medusa is and always has been the epitome of beauty, grace, charm, the perfect embodiment of womanhood. You have, I’m sure, seen her, been with her and felt the strange allure. That is Medusa. Think of history, the great beauties men have given their very being to possess; women that men have fought and died for: Helen of Troy, Nefirtiti, Bathsheba, and how many other nameless women. She was all of them. Medusa was Solomon’s favorite concubine, coming to his chamber night after night, she was consort to Roman Emperors, Arthur’s Guinevere and so many more. She is ageless and she is timeless, yet through it all she suffers.”
“Suffers?” I asked. “I would have thought she would have everything she could want, but, from what I’ve seen, she has nothing.”
“Of course she has nothing. She wants nothing but to be alone, to be removed from the curse?”
“I still don’t understand,” I had to admit.
“That is because all you see is a beautiful woman and in your mind beauty opens many doors. You feel the intoxication, but don’t see that there is a person there. I, on the other hand, know what she wants all too well and I can help free her from her sorrow. I have pursued her for all these years, because I want to take her away and free her from her burden.”
I listened closely, not sure if any of it was true or if this Mr. Persy was merely a pimp trying to get his hooker to tow the line.
After a bit of thought and reflection, I knew that it was up to Medusa to make some sort of decision.
“Wait here, Mr. Persy,” I instructed.
I went back to our break room. Medusa was still there, still wrapped in the blanket, sitting on the chair with her arms holding her knees tightly to her chest, slowly rocking back and forth.
“I’m still cold,” she cooed and then she gave me her smile and I knew why men throughout the ages would fight and die over her. But, my professional demeanor took over.
“There’s a man here looking for you, Medusa. He says his name is Mr. Persy. Do you know him?” I asked softly.
I put my hand on her shoulder and she pulled away and shook her head violently back and forth.
“NO, NO and NO,” she shouted. “DON’T LET HIM, DON’T LET HIM, please?”
I saw the fear of the caged animal in her eyes as the door burst open and Mr. Persy entered.
‘Medusa, my Medusa, you’ve eluded me for so long, but now I’ve found you, alone, and I will have my victory. I will fulfill the task set before me and she will be mine forever,” Persy hissed.
“You’re mad, Perseus. She’s been dead for thousands of years. No matter what you do to me you can’t have her. She’s probably nothing but dust by now, dirt which has grown op and become grass, then consumed by some lowly animal, a cow perhaps, or a bull, or the Minotaur. Yes, consumed and digested and rejected like dung. That’s all your precious Andromeda is; Minotaur dung and that’s all you deserve.”
Miss James came in to check out all the commotion, startling Mr. Persy, that is Perseus, and I took the opportunity to step between Medusa and Perseus, but the crazed Greek “hero” pushed us all away, reached into his overcoat and pulled out a very long, very sharp gleaming knife.
“There is no help for you here. No king’s guards to protect you, no smitten Alexander to offer you refuge. Only these pitiful mortals. I’ll have your head and my happiness. Andromeda will be free and we will fly away together.”
He moved closer towards Medusa, his knife held high.
I heard a loud thump in the waiting room.
Maybe it’s the police or a disgruntled patient tired of waiting.
There was a loud crash as the door to the break room ripped away from its hinges and fell to the floor. A sleek white horse bolted through, its black eyes determined, white wings sprouted from its back as it reared up and brought its front legs down on Perseus, knocking him to the floor and then kicking him to the side like a the piece of garbage he truly was.
The winged horse bounded towards Medusa and she effortlessly climbed on its back. The powerful beast kicked a huge hole in the back wall and the two rode off into the east towards the just rising sun. A faint glow arose from horse and Mistress as the snow fell around them and they made their escape. Miss James and I stood silently and watched.
“Perseus,” I exclaimed.
He was up on his feet, brandishing his knife at us.
“I have no quarrel with either of you. But, if you should ever see her, call me. The things I told you are all true. What she said is mere fantasy; the product of a deranged mind. I bid you farewell.”
He left a card on the table and stepped towards the opening in the wall.
“But, let us check you. You may be seriously injured. Pegasus’ kick packs quite a wallop.”
“I have lived for all these thousands of years and suffered far greater injury than a trifling kick from an old nag.”
He stepped through the hole in the wall and was gone. I looked up to see him flying towards the east, his boots had wings.
Like Hermes’ boots.
I turned away and looked into my companion’s eyes.
“Do you believe any of this, Miss James?” I asked.
“What’s not to believe? There is a big hole in the wall and then there is him.”
She gestured for me to look behind and there, standing in the doorway, was the Minotaur. He was dressed in a black suit and had a gold ring on his finger, but there was no doubt as to the beast’s identity.
“This is not some sort of Halloween gag, is it? Because, trick or treat and Halloween were months ago.”
“I’m sorry,” the monster apologized, speaking impeccable English with a slight accent. “I saw that you’re light was on and that you were open, so I thought you might be able to help me. You see I have this rash…”
“Miss James, would please take Mr. Minotaur…”
“Just the Minotaur, if you please. It commands more respect.”
“Would you please take the Minotaur to room one. I’ll be there in a few minutes.”
What time is it? Isn’t this shift over yet? Five thirty, an hour and a half to go. I guess I need to face the Minotaur.
I did remember reading something about the Minotaur recently, but the details eluded me at that moment.
I knocked on the door to room one as I glanced at the chart:
Quinton Arbus Taurus Aegus Minos, “Minotaur”, DOB unknown, originally from Crete, previous neck trauma, recently hospitalized following severe exposure with dehydration, previously prolonged exposure to cold, starvation…chief complaint: rash on upper chest.
“Good evening, Minotaur, or rather, good morning. What’s the problem that brings you in this fine morning?” I asked, trying to maintain my professional appearance.
“I’ve had this rash along my upper chest for almost two weeks now, right where my body transitions from fur to hairless skin. I’ve tried all the usual creams and nothing is working. It’s driving me crazy,” he reported, his manner polite and refined.
“You’re in luck. I’ve been rotating through Dermatology this month. I’m pretty well up on all the rashes. Let me take a look. Does it itch a lot?
“Horribly, day and night. I can’t sleep. I thought I might have fleas, even went to the vet for a flea dip, but nothing helps.”
“Well, let’s take a look.”
He took off his black overcoat and suit coat, followed by his white shirt and tie. There was an abrupt transition from the short, coarse hair of his bullish shoulders, neck and head to the smooth white skin of his human half. At this changeover point the skin was red and thickened with vesicular lesions. There was some excoriation where the Minotaur had been scratching.
Very strange, very unusual indeed.
“I need to take a closer look at the hairline, but I think I know what the problem is,” I informed the Minotaur. I found a magnifying glass in the exam room drawer and began a very close inspection of the beast’s hair. Sure enough they were there, tiny whitish “nits” on the hair and I noticed some tiny bugs moving about.
“You, my dear Minotaur, have lice. I’m surprised the flea dip didn’t help, but sometimes these tiny monsters can be very tenacious. Give me some time and I’ll do my best to get rid of most of them. It might be best to shave a lot of your hair, particularly along this transition zone. But, first you’ll need a shampoo.”
Lice was a fairly common complaint at the clinic and we maintained a supply of medicated shampoo which usually worked well to kill any adult forms of the vermin. I gave him a vigorous lathering, let it sit for a bit and then rinsed.
Next, I pulled out a fine comb and began going through all is hair, brushing away some of the whitish eggs, while pulling out hairs that stubbornly held on to their cargo. This, I had learned over the years, was the only way to get rid of the nasty “nits” which were cemented to his hair.
“While I’m working, Minotaur, I was wondering if you know anything about Medusa and Perseus? I assume you were around during their time. What is the truth?”
“A sad story, that’s for sure. The events actually took place before my birth, but I did get a firsthand account from one of the old guards in Minos’ palace, before I was locked away in the Labyrinth.
“Medusa always had amazing beauty, but also intelligent and wise. So beautiful, in fact, that all the lady “gods” were jealous. They concocted the story which has become the myth which has survived all these years. Medusa, one of three Gorgons, was supposed to be so ugly that anyone who looked at her would be turned to stone. She had hair which was snakes and eyes which turned anyone who gazed into them to stone. This kept most everyone away. But, this was not enough for Athena and Aphrodite. They were so jealous of her that they plotted to have her killed.
“Perseus was their dupe. He really did venture out on a quest to kill her and to bring her head to King Polydectes, as recounted in the myth, but, like most myths, that was the only kernel of truth in the story. The gods promised Perseus that he would have Andromeda as his bride if he could vanquish Medusa. Andromeda was young and very pretty and her father was very powerful. Perseus immediately was smitten by her charm and the prospect of ruling the land as the next king and vowed to return after he was successful.
“Perseus did manage to find Medusa with the aid of the gods. But, he first had to deal with Medusa’s two sisters, who were truly ugly just as it says in the myth. Their job in life was to shield their stunning, gifted sister from unwanted visitors. Perseus was a truly great warrior, however, and he was determined to vanquish Medusa. He brutally murdered Medusa’s sisters.
“He came upon the young, innocent, beautiful maiden and threatened to kill her if he did not tell him where he could find the supremely ugly Medusa. He was still expecting a Medusa with snakes for hair and hideously gnarled features, which is what the entire world assumed Medusa to be. That young maiden, who really was Medusa, realized the danger she was in and tricked Perseus. She sent him up into the hills, saying that the repulsive Medusa was in one of the caves. Perseus charged up the incline, his sword raised and his shiny shield slung over his back, ready to do battle with a monster. Meanwhile, Medusa made her escape on the back of Pegasus. And she’s been on the run ever since.
“It’s sad, so sad,” he continued. “Medusa has only good qualities. She has to be the most beautiful and tragic woman to ever live. Meanwhile, Perseus has lived with this obsession for thousands of years. Andromeda is long dead, the Greek gods have been relegated to myth; only a few of us live on. Myself, Pandora, Perseus, Medusa, Hercules, and a few more have survived through the ages, through all the sordid years of human history.
“Pegasus, by the way, the winged horse, is Medusa’s greatest friend and ally. She raised him from a colt and he is never far away from her. That is one reason she has managed to survive and escape all these years.”
The Minotaur finished his story and sat while I continued to comb through his hair. Miss James, by this time, had joined me.
“Finished,” I announced. “I think all the nasty little creatures and their eggs are gone. To be really thorough you could slather on some olive oil and leave it over night. That will suffocate any little beasts who may be lingering. Oh, and good look on you new job at the University. I do remember reading about you and your remarkable life in the paper. I think you will turn the Department of Antiquities on its head.”
“Thank you, doctor and nurse,” the Minotaur answered. “I wish you well. And, don’t worry about Medusa. She will be alright. Look for her, someday, on a movie screen or on the arm of a powerful senator or prince. Oh, and look for my story. I think you would enjoy it. Good morning.”
And he left.
Miss James and I stared at each other, shrugged our shoulders and waited for the next shift.
“Breakfast? Or a bath?” she asked.
“Both,” I answered.
A few minutes later we left together.
Sunday, November 17, 2013
Today, for an unknown reason, I thought about sitting at the bedside of patients. I wasn’t thinking about sitting down in the consultation room when first meeting new patients that crossed my mind, although this is always a good practice. This type of sitting sends the patient the message that you care about them and are willing to spend the time to listen them. Rather, it was sitting at the bedside of a very sick patient; being right there to tend to their needs should an urgent situation or sudden change develop.
That’s the nurse’s job, one may say, and that would be correct. But, sometimes, it’s a doctor who needs to be present. I never was part of such a scenario while in medical school. I did see sick patients as a medical student, but, as a student, was never allowed to truly get involved in their care. My first experience with a really sick patient was during the first month of surgical internship.
One night on call I was called to the ER for a patient who had been stabbed in the upper abdomen. The patient was unstable, with severe tachycardia,hypotension and a stab wound between the xiphoid process of his sternum and his umbilicus. He was whisked away to the OR in short order, where the Chief resident and second year resident spent the better part of the evening battling to keep the patient, Jose Gonzales, alive. He had suffered injuries to the stomach, colon, superior mesenteric artery and vein and duodenum. I wasn’t with them in surgery, but I did receive a call at about one am to come to the ICU. They had just brought Mr. Gonzales from surgery and it was now my job to sit with him and attend to his needs.
I immediately noted the drains coming out of his abdomen, filling up with bright red blood.
“Just transfuse him as needed,” were all the instructions I was given.
I gave him a quick once over. His pupils were nonreactive, his extremities were cold, there was no urine forthcoming from the Foley and three abdominal drains were already filled with blood. His heart rate was 130 and BP 75/35. I pulled up a chair, but didn’t sit. For the next four hours the nurse and I pumped blood and plasma and platelets and cryoprecipitate and more blood into poor Mr. Gonzales. As fast as we pumped it in, it ran out: through the drains, through his mouth, through his endotracheal tube, from everywhere. It was my first encounter with a severe coagulaopathy. He was cold, he had already received massive volumes of transfusions and his blood would not clot.
Finally, shortly after five am, I called the Chief resident and asked this question:
“How long do you want me to do this?”
I explained the situation and told him that Mr. Gonzales had been transfused over two hundred units of blood products and we were still at square one. I knew I was just a lowly intern, but I gave my opinion anyway.
“I think it’s hopeless.”
My Chief agreed and we stopped. Mr, Gonzales died about one hour later, never having regained consciousness or any signs of life.
Although Mr. Gonzales may have been the most desperate and intense bedside vigil I’ve sat through over my many years in practice, there have been many more.
I’ve written about some in my books, Behind the Mask and Under the Drape. Chapters in those books recount my experience with one unnamed patient who had a stormy immediate post op course after an elective aortic aneurysm repair and with Gerald, who experienced one complication after another and required multiple operations, surviving the worst case of ARDS (Adult Respiratory Distress Syndrome) I’ve ever seen.
These examples demonstrate that a sick patient often requires constant vigilance. It has been my practice to stay with my very sick patients in the immediate postoperative period until I’m sure they are stable. Most of the time this is a short vigil, sometimes only a brief visit in the Recovery Room or ICU, while at other times I will stand at the foot of the bed, staring at the monitors and foley bag, waiting and hoping and praying for the blood pressure to rise or the urine to start flowing or the pulse oximeter to begin displaying a true waveform, while trying to decide if I’ve forgotten something important or if something else needs to be done. Such physiologic indicators all tell me the same thing. When they are good it means that the patient is probably perfusing vital organs adequately, but when they are bad then the whole patient is bad.
Dora was such a patient. She was old, almost ninety. She had lived in the county run nursing home for longer than she could recall. She came one evening with a very distended abdomen, obstipation and vomiting. She told me her belly had been hurting for three days. In the course of my evaluation I asked her how old she was.
She answered, “Old enough to know better.”
Her workup suggested a cecal volvulus with perforation. This means that the right side of her colon had become twisted, then blew up like a balloon and finally popped, causing peritonitis, a very serious, life threatening condition. She arrived in surgery at about ten o’clock at night and underwent a right colon resection and ileostomy. This means the right side of her colon was removed and then the end was brought out to the abdominal wall where it would empty into a bag, like a colostomy except involving the small bowel rather than the large bowel. The reason the surgery is done this way is that in a very sick patient healing is of major concern and reconnecting (anastamosing) the two ends of the bowel may not be successful, which could lead to a similar problem all over again.
Surgery finished around midnight. I stayed around in the ICU while she woke up. Her blood pressure hovered in the 70/30 range and her urine output was minimal. I was in and out of the ICU, ordering fluid boluses, anxiously awaited lab reports, watching the Foley bag, trying to wish a few drops of urine into the tubing.
Dora lay still in her bed, although she did open her eyes after a while. Her post op CBC came back and the hemoglobin was higher than it had been pre-operatively, even though she had not been transfused any blood. I checked again. Sure enough, her preop hemoglobin/hematocrit was 11.1/33.3 and now it was 11.6/35.0. These numbers told me two things. First, it was unlikely that she was bleeding and second, that she was hypovolemic. I drew these conclusions because bleeding will cause the hemoglobin level to fall. This fall may not always be immediately apparent, but in a patient like Dora, who had already received large volumes of IV fluids, bleeding of any significance would almost surely cause the hemoglobin level to fall.
The fact that she was hypovolemic can be concluded because the rise in hemoglobin suggests hemoconcentration, a long word which means she had lost fluid from her blood stream or intravascular space into the surrounding tissues, the extravascular space. Think of the blood vessels as a sieve. Fill the sieve with marbles and water. Before pouring the mixture into the sieve the combined volume of marbles and water may be one quart, with 50% of the volume marbles and 50% water. The marble level can be considered to be 50%. But, when you pour the mixture into the sieve, the water leaks out and the marble level becomes 100%. The hematocrit level is akin to the marbles, that is it is the percentage of blood volume made up by red blood cells. The fact that it has gone up suggests that fluid has been lost from the intravascular space (bloodstream) into the extravascular space. The bottom line was that she needed more intravenous fluid to fill up her tank, that is the intravascular space.
I stayed at her bedside for a bit more than two hours, until I was sure she was stable, then disappeared for a few hours of sleep before the next day’s trials began. Dora, after the first few rocky hours, perked up and sailed through her postoperative period like a twenty year old. I was able to do surgery to reverse her ileostomy about three months later.
Two years later I was called to see and elderly lady with a distended abdomen. Small bowel obstruction was suspected. I went to the ER and found a very old patient with a very distended abdomen.
I asked her how old she was and she answered, “Old enough to know better.”
“Dora, how nice to see you again,” I answered. “I wish we could meet under different circumstances sometime, however.”
She agreed. Her X-Rays suggested she had a small bowel obstruction and lab tests were worrisome for ischemic or gangrenous bowel. Therefore, at about eleven o’clock that night she went back to surgery where I lysed adhesions, resected an ugly segment of gangrenous bowel and settled down at her bedside and repeated the events of two and half years before.
Once again, after a suffering through a few hours where her condition was touch and go, she stabilized and made an uneventful recovery. I didn’t have the pleasure of seeing her again and I don’t know at what age she finally passed away, but I hope I gave a few more years of quality life.
I still make it a habit of staying around until my patients are stable after major surgery, particularly when the patient has a life threatening condition like those suffered by Dora and Jose. I don’t seem to have to do it as often as I used to. I credit this to improved intraoperative care by anesthesia, better preoperative preparation and, maybe a bit of fortune which has allowed me to avoid operating on extremely ill patients in the middle of the night.
One question does remain.
Have I ever sat at a patient’s bedside just to sit with them?
What I mean is have I ever had a patient who I had grown close enough to and who was so ill that I wanted to stay with them just out of concern and worry over their condition? Even if there was nothing I could do?
I actually thought about this before I even began writing this article about being at the bedside and then, ironically, it came to the forefront during a recent conversation, which was held in the operating room while removing a nasty appendix. The anesthesiologist and circulating nurse asked me just that question. Apparently the topic had come up during the day and they wanted my input.
I thought for a while and I couldn’t come to a definite answer.
I have had innumerable patients over the years I in whom I have a taken a personal interest in their care. Most often these were very sick ICU patients who needed very close attention as their condition had the potential to rapidly deteriorate. Patients like Albert who was admitted with a Neurosurgical condition, but developed sepsis from an intraabdominal source, requiring emergency surgery, and Doris, a victim of a motor vehicle accident who had a missed colon injury and came to our ICU with severe sepsis, or John who also came to the ICU after inadequate treatment for a perforated colon.
These and so many other patients have received my utmost, careful attention to help them through the most critical parts of what were often very complicated illnesses. I never, however, developed a truly personal relationship with any of these patients. I only saw them in a professional sense during their illness and once or twice after they had recovered. I never went out with them for a drink or to play golf. I guess I have taken the medical school teaching to heart: Maintain a detached concern.
The acute nature of surgical diseases, particularly general surgical conditions, rarely allows the development of a close relationship prior to a surgical intervention. Even those patients with cancer who are scheduled to undergo surgery are seen only once or twice before their operations. I care a great deal about my patients from a professional perspective. But, I see my task as one of helping them through the most serious part of an illness or injury; to get them healthy enough to return to their lives apart from being sick. That is the job of a surgeon.
Perhaps, however, I am missing something?
Sunday, November 10, 2013
“I’m here again, ready for another adventure into Never Never Land,” I announced as I blasted through the door which led to the clinic work station.
“You have some nerve showing up here,” Miss James remarked. “I waited for two hours outside the concert hall. It’s too bad, you missed a great show.” There was a touch of venom in her voice.
“Didn’t you get my message? I’m sure I sent one. Dr. Mercal sent over a sick lady from his office. It was too much for the intern to handle. So I was stuck.”
“No, I didn’t get any message. And then I expected you to at least show up at my apartment afterwards.”
“I didn’t finish with that patient until two am. She turned out to have Legionella and a perforated ulcer. Couldn’t find the surgery attending for two hours. It was Bastrock, of course, probably off with one of his floozies. I wouldn’t mind so much if he was a better surgeon, but his patients always have problems. I wish they would take him off the call roster. I’m sorry. Love. I’ll make it up to you, I promise.”
“And, one more thing. Have you made a decision yet? My lease is up in six weeks, you know. They’re pestering me to renew.”
“You know I wouldn’t stay in that apartment any longer, no matter what. It’s too small and drafty and all the appliances are pretty much on their last legs.”
“True, true, but the price sure is right. Anyway, it’s time to get to work. Caleb, the artist is in two, severe headache.”
“Caleb the artist? Should I know him?”
“Probably not personally, although you probably know his work. He’s a street artist around here; he’s done murals and such on the sides of most of the buildings. I think he’s quite talented. He did this sketch for me while he was waiting.”
Miss James held up a drawing in pencil of our clinic, the light over the door, the neon word “Clinic” in the window along with the red cross symbol for hospital. Our storefront clinic stood out from the buildings around the neighborhood. Even in that sketch there was something that shouted “Come here and be made whole.” I looked forward to meeting this Caleb.
I knocked on the door and went into exam room two and announced my presence in the usual way.
“Good evening, Mr….” I glanced at his chart. The only name was Caleb, no address, no phone number, just a single name.
I stumbled a bit, “Uh, Caleb, I’m Dr. Barnes. What brought you in here today?”
He didn’t reply immediately. The room was darker than usual. The only light was from the X-ray box, which provided a soft illumination. Caleb was facing the far wall, his arm dancing back and forth. I noticed a long pony tail, leather jacket and blue jeans. He ignored me and kept on working, creating a mural on our blank exam room wall. After about a minute he turned around.
“Hello, Dr. Barnes. I’m Caleb. I hope you can help me.”
“I will certainly do my best,” I responded, doing my best to put some concern in my voice, while trying to get a glimpse at the newly created art work which now adorned are previously sparse exam room. Caleb wore dark glasses and a white bandana around his head. He put out his hand which I took, receiving a strong handshake. I glanced down at his fingers which were long and smooth.
“What is the problem you are having?” I asked.
“I’ve had this headache for about two weeks. I assumed it was nothing, but it hasn’t gone away.”
“Where do you feel it most?”
“Right in front, like someone is boring into my brain. The light makes it worse.”
“Have you tried taking anything? Tylenol, Motrin?”
“I’ve taken some expired Ibuprofen which helps a little bit, maybe for about an hour, but then it comes back. It seems better in the mornings when I first get up, but by afternoon I can barely move, it’s so bad sometimes.”
“Any other medical problems? Heart, kidney, abdominal pain, nausea, vomiting, fever, weight loss?”
“Take any medications, any allergies, rash, blurred vision, or any visual changes?”
“No, except the light bothers me.”
“OK, OK. Let me check you. I need to turn on the light.”
“Go ahead, I’ll be OK.”
“Let me check a few things with the lights off first.”
I took out my flashlight and shined it in his eyes. His pupils reacted briskly.
“I’m no Opthamologist and I haven’t done this since fourth year, but I’ll give it a try. I picked up the opthalmoscope and aimed it towards his eyes. I was greeted by the red reflex and was able to get a clear look at his retina.
Still have the old touch. But, what am I looking for?
I could see blood vessels and the optic nerve, but had no idea if any of it was pathologic.
Where’s the CT Scanner when you need it?
“I’m going to turn the lights on now.”
“OK,” he answered, but there was a sense of apprehension, almost doom as I flicked the switch.
Caleb winced and squinted when the light came on, then put his hands to his temples and rubbed them vigorously as if he was trying to vanquish the demons that were pounding on his head.
“I’ll try to be quick,” I assured him as I auscultated, palpated and inspected form head to toe. Everything was normal. I turned the light off as Miss James stuck her head in the room.
“I need you in three. An elderly man just came in, wheezing, blue lips, doesn’t look too good. I put him on a hundred per cent oxygen.”
“Did you call for an ambulance?”
“Started to, but the man said he wouldn’t go to the hospital.”
“I’ll be back in few minutes, Caleb. Just lay here with the lights off, that’ll probably help.”
I glanced at the chart outside exam room three.
“Heinrich Dietrich, ninety three,” I murmured as I quickly knocked and opened the door.
“Good evening, Mr. Dietrich, I’m Dr. Barnes,” I started with my usual bedside banter.
I was greeted by the raspy sound of labored breathing. Mr. Dietrich was sitting upright, his chest heaving as each breath came with herculean effort. His lips were blue, his eyes sunken deep into their sockets. His skin was a grayish yellow with superficial scratches and healing sores. I understood immediately why he didn’t want to go to the hospital.
“Terminal?” I asked.
He nodded in the affirmative.
“What can I do for you?”
He handed me a piece of paper and gestured for me to read it.
“Chaim Fiesel, 3233 Elm, #11”
“Send for him…Please,” he requested, his voice, with a bit of an accent, a barely audible rasp.
“But, I can’t…”
“PLEASE,” this time almost a command.
I looked at the paper and then at my dying patient.
“OK,” I answered.
I left the room and found Miss James at the nurse’s station.
“Anything else waiting?” I asked, sort of nonchalantly.
“Quiet as a mouse. What’s going on in three?”
“Mr. Deitrich has terminal cancer. He’s dying and he knows it. He asked me to find this man, a Chaim Fiesel. He’s supposed to be in an apartment over on Elm, only about five minutes away. I thought, maybe, one of us could run over and fetch him. You know, grant the dying man his last request.”
“I’ll go,” she replied. “that way if anything bad comes in you can take care of it.”
“I hate to let you go by yourself. It may not be safe.”
“I’ll be OK. I know that apartment building. It has a big, mean, watchdog and is pretty secure. It should only take a few minutes, assuming Mr. Fiesel is there and will come with me.”
She was out the door in thirty seconds and I manned the front desk. A woman came in with her child suffering from an earache. They were quickly examined, diagnosed, treated and out the door. I went back to check on Caleb. He was up on a chair, creating a new masterpiece on the wall. All I could make out in the dim light were shades of black, gray and white.
I heard the door open and saw Miss James and a short, bent, elderly man come in. He was dressed in a dark gray suit, wore thick glasses and had a dark gray moustache. His eyes however, were alive, a vibrant blue. I hurried to meet them.
“Dr. Barnes, this is Mr. Fiesel,” she reported as the man put out his hand. I noticed the fingers were bent and twisted.
“Nice to meet you,” I said, taking his hand in mine, giving him a strong greeting. “Did the lovely Miss James explain the situation?”
“She did, she did,” he answered, his voice marked by an Eastern European accent, not much different from Mr. Dietrich’s. “I do not know this Heinrich Dietrich and I do not know why he would ask for me. Perhaps, you can find out more?”
“I’ll go ask,” I replied. “Maybe he’s a long lost relative and wants to leave you some money. He is dying, you know.”
“Yes, yes, Miss James did tell me that.”
I returned to room three. Mr. Dietrich seemed a bit more comfortable.
“Mr. Fiesel is here, but he is wondering why you asked for him. He says he does not know you.”
“It’s true, he does not, but in a way he does. Tell him I must see him. I must tell him I’m sorry.”
“Sorry? Sorry for what,” I had to ask. “I ask you because I know that he will ask me.”
“Sorry for what I did, to him, to his people, during the war at Dachau.”
Now it was clear to me. Mr. Dietrich, with his clearly German accent. Mr. Fiesel, a Jew, also German, perhaps a survivor of one of the camps, all adding up to a search for peace on one’s deathbed.
“I’ll carry your message to him,” I whispered in Mr. Dietrich’s ear.
I hope Fiesel understands.
I went back to the lobby where Mr. Fiesel was waiting and explained the situation. Fiesel’s face turned red as he heard my report.
“I was in Dachau; my whole family, mother father, two sisters, died at Dachau. He may have been their executioner, for all I know,” his voice was growing louder. “I should hear the confession of a murderer, a man who served in a place that took my whole life from me? No, I will not. I cannot.”
“But surely you can find it within yourself to forgive, to give this man some peace before he goes?” Miss James asked.
But Fiesel said nothing. He sat down and stared at his gnarled hands.
“I was a violinist,” he said softly. “I started playing at the age of two. I was the youngest performer ever with the Munich Symphony. But, they took that from me.” His voice started to rise and tremble. “Look at these hands, look at what they did to my hands. First they smashed my violin into a million splinters, then they smashed my hands.”
And I saw his broken hands, reflections of a broken soul. I left him and returned to the dying Dietrich, but first I saw a light coming from exam one. I had almost forgotten about Caleb. I opened the door and saw him sitting up in the chair. And, I saw his finished mural. It was a scene of horror. A death camp surrounded by barbed wire, emaciated bodies withering away and dying while soldiers brandishing rifles watched, laughed and did nothing. The sky was filled with black clouds which matched the blackness of death in that camp. Except, at the end of the mural there was a bit of yellow, a sliver of sunlight which illuminated a corner of the camp where one soldier was stooping down, giving a red apple to a boy. The boy was like the rest of the prison, wasted, dying, dressed in a ragged striped uniform.
I felt a body brush up against me. I turned, expecting to see Miss James, and was a bit surprised to see Mr. Fiesel. Tears were streaming down his face. He looked up at me and then left me and went into exam room three.
I continued to stare at that mural adorning the room’s previously empty wall. It was a masterpiece of death and hope. The blacks and grays, the ominous clouds, the pall of death which hung over that camp were all overshadowed by the small expression of kindness set off to one side. In the midst of all that despair, one glimmer of hope shined through. I turned to offer my critique to Caleb, but he was gone.
Mr. Fiesel emerged from room three shaking his head, but also smiling.
“You see,” I began to comment, “a bit of forgiveness…”
He held up his hand to stop me. Miss James stood at my side to hear his story.
“You don’t understand, Dr. Barnes, neither of you do. This picture, this vision of death with its small ray of light illuminating a solitary act of human decency is not just an abstract artist’s interpretation. All that death, all those guards and barbed wire is exactly as it was. And, that soldier giving the apple to that little boy is real. That little boy is me. Look at the date on the picture. September 13, 1943. I remember that day, it was my birthday. I turned ten on that day. I was so hungry, I thought I wouldn’t live for another minute if I didn’t get something to eat. One of the guards took pity on me. He was about to eat an apple and must have seen me staring at him. He smiled at me and then got up and came to me. He bent over and gave me that apple and, along with it, gave me the hope and will to survive. You see, I was all alone, my family was gone, murdered by the Nazis; all I could hope for was death, disease and despair. But, he gave me hope and I did survive. I never became the musician I should have been, the Nazi’s made sure of that, but I did come to this country and became an art dealer. This picture reminded me that in the midst of hatred and chaos and evil, human kindness still may exist.”
“Is that why you changed your mind? To pass on this human kindness?” I asked.
“Maybe,” he answered, “but there is even more. Look at the image closely, look at the helmet.”
We bent over and stared at the soldier and saw, clearly on the brim of the helmet the letters HD.
“Heinrich Dietrich, the dead man in your exam room is the soldier in this mural. He gave me his apple and a second chance at life and I had to thank him. You know, Dr. Barnes, he lived only two blocks from me for over thirty years but I never realized it and he could never gather the courage to come to me. He told me now he would walk past my art gallery; he did this hundreds of times. He even found the courage to come inside once. He asked for me, but when I came out he had left. When I saw him today I knew him immediately. He asked my forgiveness. He offered no explanations or rationalizations. He knew what was done, what he had done, how he had helped it all happen and how he had done nothing to stop it. Yet through all that evil, there still existed this one tiny shred of humanity.”
We three stared at the painting for a bit longer.
“Where is the artist?” Fiesel asked. “I would like to meet him and thank him personally.”
“Caleb; he must have left. He lives somewhere in this neighborhood, I’m not sure exactly where. I’m sure you’ve seen his work all around. He has created murals, like this one, all over the city.”
“I have seen them, it is truly remarkable work, a wonderful talent, but, perhaps in need of a little guidance,” Fiesel murmured. “I will have to search for him. After all, I am an art dealer.”
He shook my hand and gave Miss James a light peck on her cheek and went away.
It was coming up on seven when he left, almost the end of our shift.
“What should we do with this mural?” I wondered. “I don’t think it is quite right for a medical clinic.”
“Death, despair and hope?” Miss James said out loud. “Isn’t that what we deal in here?”
“Perhaps…but not in that order,” I observed.
“I’ll tell you what,” she replied. “I’ll call up Fiesel later today and ask him if he wants it for his gallery. I’m sure he can figure out a way to get it from here to there.”
I snapped photo of the mural, just in case it was somehow lost, and then we went back to the nursing station and found a final gift from Caleb.
On the desk was another picture, bright and colorful. It was my apartment. Seated on the couch were two people, myself and Miss James. There was an open door which showed the bedroom and the bathroom, with two towels on the rack and two toothbrushes hanging by the sink. Next to the drawing was a note.
“My headache is gone. Thank you so much, Dr. Barnes.”
Miss James and I stared at each other and then, almost simultaneously asked.
“How does he know?”
We didn’t have an answer.