I had not been an intern more than three weeks when the ward nurse roused me at two A.M. because an eighty year old man was short of breath. He was more than that. He was bubbling over in pulmonary edema, literally. Froth of yellow, blood tinged stuff was spilling out of his mouth.
The nurse looked to me for orders and I told her to get the crash cart, and when she returned I ticked off each step I had been taught to do: I slapped in two large bore intravenous lines, one in each arm, gave him morphine through one and furosemide through the other. She inserted a catheter through his urethra into his bladder which she hooked up to a Foley catheter so we could see if he was responding to the furosemide by making urine. We hooked up an electrocardiogram and I ran off a twelve lead and could see the wildly elevated ST-T wave segments and knew he was well into a myocardial infarction.
We applied rotating tourniquets from the crash cart, one on each arm and leg.
All this took about fifteen minutes and he was still gasping for breath.
The nurse asked if I wanted to call the cardiac team, but to my mind the cardiac team was for cardiac arrests and he hadn’t arrested, yet. I didn’t want to sound a general alarm and wake an anesthesiologist (who would intubate him and hook him up to a respirator) a senior resident, a cardiology fellow until I had run through every step I had been taught.
I can’t say I had been drilled on any of this, but we had gone over this stuff in a session the first week of internship.
“He’s not looking so good,” the nurse said. “He’s not responding.”
I asked for the phlebotomy bottles. She wasn’t sure she knew what phlebotomy bottles were. I described them to her as they had been described to me and she remembered seeing them in a cabinet. She arrived and they were just as advertised and I plunged the business end of a large bore needle into the patient’s femoral artery and one liter of blood was sucked out of him and filled the glass bottle faster than Jack pops out of a box.
The patient drew in a deep sigh and said, “Oh, that did it. Much better.”
We had broken his pulmonary edema.
I called the cardiac care unit and the resident, a year ahead of me in training came down and looked at the EKG and heard the story and said, “Good job.”
I was one proud intern.
The next day, on morning ward rounds the head nurse, who had been a head nurse about ten years and whose opinion mattered to me, looked at me when we arrived at the patient’s empty room—he had been trundled off to the cardiac care unit—and she said, “So I hear you do not flinch when the battle is joined.”
That made a lot of afternoons spent in malodorous organic chemistry laboratories on beautiful fall afternoons all worthwhile.
Last night I watched Master and Commander ,again. I love that movie for many reasons, but one of the most important is it is a wonderful coming of age story, and the scene where Captain Jack Aubrey continues his lesson on the use of the sextant to his midshipmen as the French cannon balls whiz around them, ignoring all that as an annoying distraction resonated with some of my own training on the wards.
But more than that, is the picture of what it is to be a man, a leader, a hero, to stand fast and not to falter and to grow and to do things which require training and heart and execution. It’s all there.
Jack Aubrey decides to pursue the dangerous foe, to take risks, to put his exhausted crew and himself through great travails because that is what it means to be a warrior, to defend his nation on the last battlefront before invasion of the homeland.
I mention all this because just this past week we had a discussion at our Clinical meeting and the new reality of medical practice became apparent.
We were talking about getting an electrocardiogram in the clinic. We are a subspecialty clinic. We take care of people with thyroid disease an diabetes. Until I arrived, I infer, none of the doctors listened to any patient’s heart with any regularity. They did “focused” physical exams, which is to say, they palpated the thyroid on thyroid patients or looked in the eyes at the retina on diabetics.
I listen to the heart on diabetics, on the grounds diabetes is a major risk factor for heart disease.
But if the patient has heart disease, my younger colleagues argued, that’s not our job. Send the patient to the cardiologist or to his primary care doctor or nurse.
But when I listen, about twice a week, I hear a rhythm disturbance called atrial fibrillation, or what might be atrial fibrillation (AF). AF causes strokes, so if the patient has new onset AF, then we should make that diagnosis and call his cardiologist and get him seen so he can be anticoagulated.
Just send him to the Emergency Room if you are worried, I was told.
But think how you’d feel, if you were the patient. You might not even need to go to the ER, if all I’m hearing is the more benign APCs or VPCs.
No, said the young woman doctor who is my colleague, she did not want to be responsible for interpreting the EKG. She could get it wrong and get sued.
My younger male colleague, who is a very bright man and a very well trained subspecialist said, “You know the one time I did think I heard something and got you and we went over to the medical clinic and got the EKG, it put us both behind by almost an hour. And we’ve got to see fourteen patients a day. We just don’t have time to get involved like that.”
The nurse manager pointed out we had no method in place to bill for EKG’s and the extra time spent would not be credited to our “Productivity Assessment.”
Later she came by and said, “You are an old dinosaur. You were trained to put the patient first. It’s not about that any more.”
And I thought of a dermatologist I saw once for a mole I wanted excised. She was perfectly well trained to do this but she didn’t want to, because, she said, she had set up her beautiful office with its section of skin care products she sold by the front desk and she had an idea of what her practice would be like and it made her uncomfortable to think if this pigmented lesion did turn out to be a melanoma then she’d have to call me with the news, which would be unpleasant for her.
This is a woman who trained at Duke and Harvard.
And I thought back to a time decades earlier, when I was a fourth year medical student and I had just finished a six week rotation in dermatology, and I had loved the surgical aspect of it and the immediacy of the diagnoses and I had a form for the Chief of Medicine to fill out recommending me for a dermatology residency and he said, “You want to be a dermatologist?” I gulped hard. “We’ve taught you how to save lives and you want to be a dermatologist?”
I withdrew the paper and slunk out of the room.
Now dermatology residencies are great prizes. Only the top of the class. No call. No nights. No weekends. But most of all, tons of money. Move through those exam rooms fast as you can and charge lots of money for small procedures. And no stress. No worry about losing a patient bubbling over in pulmonary edema.
Jack Aubrey would puke.
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