During the first two years of medical school, the aspiring physician is mostly confined to the classroom learning the fundamentals of medicine. While these basic science courses are illuminating and at times fascinating, every medical student eagerly anticipates the transition to clinical medicine, the day he or she gets to don a white coat—a short one, the long ones are for the real doctors—and actually examine patients and begin to learn how to diagnose and treat disease. That usually happens in the third year. No longer classroom bound, the medical student spends between four and twelve weeks on a series of clinical rotations. Internal Medicine, Surgery, Pediatrics, Obstetrics and Gynecology, and Psychiatry are sequentially introduced to the eager apprentice.
I met Dr. Stranger during my third-year surgery rotation. Dr. Stranger is a pseudonym, though it is probably unnecessary since most likely the real surgeon has passed from this world—this wasn’t exactly yesterday. I refer to him as Dr. Stranger because of an anecdote he shared with our small group of medical students while we were on his service. A highly specialized and gifted surgeon like Dr. Stranger can be called upon at all hours of the day or night to perform his life-saving magic. It is not uncommon for such a physician to leave before sunrise and return well after dark, which often means not seeing his very young child for days on end. One afternoon, Dr. Stranger told us, he was able to leave the hospital early. When his eighteen month-old daughter saw him enter the house, she began to cry; she did not recognize him. Dr. Stranger concluded his story by urging our now stunned group of students to choose our specialty, not by our interest in any particular field of medicine—interesting people will find all areas of medicine stimulating, he told us—but by whether or not we had a desire to have a family with whom we could spend sufficient time so as to be recognized by our offspring. His distantly focused gaze revealed his unspoken opinion that he had not chosen wisely.
Dr. Stranger was a masterful technician and a brilliant diagnostician. But it was neither of these admirable skills that I recall most about Dr. Stranger. Rather, it was this statement that he uttered during the midst of my six-week surgery rotation: “It is not necessary for a doctor to have had an appendectomy in order for him to appreciate the pain and discomfort his appendectomy patient is experiencing.”
Dr. Stranger was referencing empathy. One need not be a physician—or any type of medical personnel—to benefit from that statement. Extrapolating Dr. Stranger’s insight, one doesn’t have to be frightened or in pain to empathize with one who is. I have always kept Dr. Stranger’s wisdom close at hand. A patient usually has no idea if her doctor is a genius or a dud. What she knows right away is if her doctor cares.
I once had a mother inform me that one of my younger colleagues had been rude to her teenage daughter during a diagnostic procedure. I found that hard to believe, but I asked that colleague if it were true. Amazingly he admitted he had indeed been quite short with the young girl. When I inquired why, he answered, “I was having a bad day.” He then asked of me, “Haven’t you ever had a bad day?” “Of course,” I responded, “but I have never let a patient know it.”
Like every practicing physician I’ve made medical errors, but I have never been intentionally rude to a patient. A patient doesn’t care if her doctor is having a bad day. She doesn’t care if he was up all night, or if his car wouldn’t start, or if his spouse is angry with him. She need not care; that is not her responsibility. When a patient seeks medical attention she is ill, or worried that she might be. The job of the physician is to hear her story, empathize with her plight, and do whatever he can to fix the problem.
Good physicians do their best to empathize. But as I have come to appreciate over the years, and every unfortunate soul knows all too well, the honest truth is that until you have personally felt hopelessly alone you cannot appreciate the degree of pain the lonely endure. The same holds for the hungry, the homeless, those with chronic pain, the terrified and the destitute. This is not contrary to Dr. Stranger’s aphorism; empathy is critically important. It’s just that no matter how sensitive or empathetic we might be, we never quite “get it” until we find ourselves in one of those unfortunate situations. “God forbid you had to walk in their shoes,” my mother would say. Until solidly ensconced in those shoes, you can get only so close to their reality.
In the fall of 2012, I was due for periodic routine screening for colon cancer. I had no symptoms; I felt quite excellent. It had been ten years since my previous screening with traditional colonoscopy and I was due for another round.
Colon cancer is the third leading cause of cancer death in the US, behind lung cancer and breast cancer. Most colon cancers arise from polyps. The vast majority of polyps do not become cancers, and the few that do grow rather slowly so there is plenty of time to locate and remove them before they can cause a problem. This is why colon cancer screening is so effective as a public health policy; appropriate screening can actually prevent 80-90% of colon cancers. It is foolish for those fifty years of age and older not to have colon cancer screening. Colon cancer can be a horrible disease if found too late, and it is highly avoidable.
In the US the most commonly performed procedure to locate colon polyps is a colonoscopsy. Colonoscopy is accomplished with a colonoscope, a very long tube with a camera at its tip that is advanced through the colon, and a gastroenterologist—a doctor who specializes in diseases of the gastrointestinal tract—views the surface of the colon looking for polyps and actual cancers. “What is the definition of a colonoscope?” the joke goes. “It’s a long tube with an asshole on either end.” (It’s all right; some of my best friends are gastroenterologists.)
As a radiologist, one of my specialties is a procedure known as a virtual colonoscopy. This examination can be performed in lieu of the traditional colonoscopy described above. With a virtual colonoscopy, no scope is introduced into the colon, so there is no risk of perforation of the colon, an uncommon but very serious potential complication of traditional colonoscopy. Anesthesia is not required for the virtual examination, whereas in most cases this is administered for traditional colonoscopy. Without anesthesia, the patient can immediately return to work or home following the virtual study, and no one need accompany the patient to the procedure. Virtual colonoscopy is highly accurate for the detection of both significant polyps and cancers—at least as good as the traditional colonoscopy. Only one out of ten patients who undergo screening with either procedure will have a polyp requiring removal; for 90% of patients no further testing or treatment is required. For these reasons President Obama had his colon cancer screening with virtual colonoscopy instead of the traditional colonoscopy.
Because of my familiarity with virtual colonoscopy—and my desire to feel Presidential—I chose this test for my own colon cancer screening. A virtual colonoscopy is actually a CT scan with a twist. You may think of it as two studies in one. The first is an analysis of the inside of the colon looking for polyps or cancers. This is accomplished with very sophisticated 3D visualization software. The second part is a routine CT scan, the kind performed for all sorts of patient complaints. So even though the virtual study is performed to find polyps and colon cancers, it offers the bonus of getting at least a cursory look at many other organs in the body. Think of it as the free steak knives with the Vegematic.
Recalling the maxim that only a fool serves as his own doctor or lawyer, I asked another colleague to review the non-colon part of my study (the steak knives part.) Since I have by far the most experience in interpreting the colon exam, I could not farm this out to be interpreted by another radiologist. My review of my colon images was completely normal; I had no polyps or colon cancer. My colleague assured me that the non-colon portion of the exam was similarly normal. I was good to go for ten more years!
Tom Stafford, former Gemini and Apollo astronaut and retired Air Force General, is as kind as he is brilliant. General Stafford commanded Apollo 10, the mission to the moon and back that preceded Neil Armstrong’s Apollo 11 moon landing. General Stafford also commanded the joint US-Soviet space program, Apollo Soyuz. Tom Stafford’s grandfather died from colon cancer, and one of his missions in life is to help others avoid this nasty disease. We became acquainted through a company that developed the sophisticated software I use to examine the colon with virtual colonoscopy.
Six months after my virtual colonoscopy General Stafford telephoned me and asked if I would spend some time educating an aide to a Congressman on the benefits of virtual colonoscopy. Congress, he told me, was interested in whether or not virtual colonoscopy should become a Medicare covered service (it should!). Of course I agreed to assist, and so I made an appointment with the Congressman’s health legislative aide to come to my office and learn about virtual colonoscopy.
I decided that the best way to explain the benefits of virtual colonoscopy was to show him an actual patient’s scan. In this era of guaranteed privacy of health information, medical personnel are forbidden to discuss a patient’s information without that patient’s permission. Fortunately, I could show the aide my own virtual study and avoid any privacy concerns.
As I was reviewing my virtual colonoscopy images, my eye lit on my left kidney. Specifically I noted that the shape of the kidney looked a bit abnormal. Having seen thousands of kidneys on these scans I was instantly certain that mine had a bulge that should not have been present. I did not reveal my observation to my guest.
For the next thirty minutes I calmly explained to the legislative aide all he needed to know about virtual colonoscopy. He thanked me, we shook hands and he headed back to Capitol Hill. I headed directly to our MRI scanner. Within an hour my suspicion was confirmed: I had kidney cancer.
Not all cancers are created equal. Some are miserably efficient, rapidly growing, destroying everything in their wake. Fortunately these are the minority of cancers. Kidney cancers, like the one growing in me, are very often more indolent, found incidentally while performing a study for another issue, just like mine was. I was pretty sure from its imaging characteristics that my tumor would be in that well-behaved group, and that I was not in any imminent danger. However, it would need to be removed; that was for sure.
It is at times such as these that it is good to be a physician, or to have one in the family. Because I teach the virtual colonoscopy procedure to physicians from around the US and the world, I have many friends in the academic medical community. I contacted some of them, and very rapidly had a short list of recommended superstar surgeons from whom to choose. Here’s a tip you might wish to jot down for future reference. When choosing a surgeon or any physician to perform a medical procedure, you don’t necessarily want the one with the highest IQ. Who you want is the one who has performed a boatload of the procedure you need. Many studies have documented that experience, not brainpower, correlates most closely with the best outcomes. “How many of these procedures have you done?” should be your first question when interviewing a prospective surgeon. You don’t really care if she has ever been president of the local Mensa society.
One of my colleagues with whom I spoke during my surgeon search was at Johns Hopkins University in Baltimore, about an hour from my home. My colleague did not hesitate for a second after hearing my story. “You must see Mohamad Allaf here at Hopkins,” he said, almost commanding me to do so. Since I had great respect for this physician, I hung up and immediately made an appointment to see Dr. Allaf. Within a week I would be traveling to Hopkins, or as I began to refer to it, The World Renowned US Medical Center.
My wife accompanied me to that initial visit with Dr. Allaf. I had done quite a bit of research on my particular form of kidney cancer, so it was simple for me to evaluate his approach to my situation. When I asked him question number one, how many of these surgeries had he done, his response was perfect: “If I haven’t done the most in the world, I am in the top five.” He wasn’t boasting; he was just stating the facts, which is exactly what I was hoping to hear. Plus he was obviously a terrifically nice guy and quite patient with my interrogation.
I have met and worked with a plethora of physicians during my career; I can spot a winner right away. Humility is in short supply at many of the best-known academic centers. While Dr. Allaf may have been employed by The World Renowned US Medical Center, it was immediately obvious that he did not suffer the hubris common to many at this and other famous institutions. I made my appointment for surgery about eight weeks later. Since there was really no medical necessity to rush to surgery, Dr. Allaf suggested I choose a day far enough in advance that the earliest appointment of the day would be available.
My surgery was scheduled for first thing in the morning on a Tuesday in late June. That was until I received a telephone call from The World Renowned US Medical Center informing me that my scheduled surgery time had been “bumped” back to 11:00 AM. This is not an infrequent occurrence. Sometimes an emergency arises and another patient needs to undergo surgery as soon as possible. Other times one patient’s surgery may take precedence because that patient has another medical problem—for example severe diabetes—for which it is best to conclude the procedure early in the day to avoid or be able to successfully manage predicted complications.
When I informed one of my non-physician friends that this had occurred, he looked at me quizzically. “But you’re a doctor, can’t you get them to do your surgery first?” Ah yes, the good old days, when having an MD after your name actually offered tangible benefits. Many of my generation were brought up on TV shows like “Marcus Welby, MD”, where a doctor enjoyed privileged status in the community. Now we physicians are just happy if we don’t get sued or find our names unflatteringly plastered all over the Internet. And honestly, medical care should be based on need, not on the postscript after your name. I was a bit disappointed but overall fine with the time change.
Surgery day minus one has its own set of diversions. I was required to come to The World Renowned US Medical Center to complete some forms and have some blood drawn. “How long could this possibly take?” I thought. I had already pre-registered in person with Dr. Allaf’s assistant for my procedure and by phone with The World Renowned US Medical Center’s scheduling team.
I arrived at The World Renowned US Medical Center and was directed to the pre-op area. My first stop was a pre pre-registration counter. When I gave my name, the somewhat disinterested woman behind the desk informed me that I must be mistaken because I was not on the list for surgery the following day. “Oh, you probably just overlooked my name,” I told her. “Why don’t you check again?” She did, and once again informed me that I was likely suffering from dementia and that she could find no evidence of my impending surgery. Of course having the patience of a saint and a terrific sense of humor (only one of these statements is true, although my wife would insist that neither is), I refrained from leaping over the counter and throttling this person who clearly could not have cared a whiff whether or not I was on her list.
I had no choice but to play the weakened but not totally ineffectual doctor card. (Foreshadowing: this tactic was to be repeated throughout my stay at The World Renowned US Medical Center.) I took out my cell phone, directly called my surgeon’s assistant, and within about twenty minutes resolved the confusion. I must admit that although I did keep my cool—well, sort of—the thought that my surgery might not proceed the following morning raised my heart rate and blood pressure considerably. When one has been primed for surgery for a couple of months even the most collected would be tested by the thought of postponement.
Having finally completed step one, I was advanced to the next line to have my blood drawn, which had to be completed before I could get to the third line to complete the registration process. At each step of the way, when my turn finally came, I was asked pretty much the exact same questions as had been proffered at frustrating stop number one, mostly about my date of birth, address, party affiliation and favorite musical group of the 1970s. I remained polite, and thanked each and every person who wasted my time. After four hours I limped out of The World Renowned US Medical Center, got into my car, and made my way home to continue the day’s requirements. More fun was to be had.
Most surgeons want your intestines to be clean and quiet when surgery commences. It’s not clear why this is required if the surgery does not actually involve opening or removing the intestines, but it’s a tradition that has carried on despite any good evidence that it matters. If you have ever had any type of abdominal surgery or even a colonoscopy, then you have experienced the privilege of commanding your intestines to release everything in their possession over a short interval of time. You have imbibed copious amounts of what I am fairly certain is “fit-for-human-consumption” automobile anti-freeze. A prolonged stay in the water closet follows this delightful escapade. In fact, you likely spent so much time in the water closet that you have discovered the precise mathematical pattern utilized in the repeating wallpaper design. No wallpaper? Then you have determined that the carpenter who constructed this room was likely inebriated at the time since there is not a true right angle to be found. Either way, you are way too familiar with a room about nine square feet in area.
My wife and I arrived at The World Renowned US Medical Center at about 9 am Tuesday morning for the rescheduled 11 am surgery. Shortly I was whisked back to the preoperative area and told to undress. This brief activity held no special significance at the time, but in retrospect this was the sentinel moment when my journey began. In order to explain why, we have to talk about underwear. A man will lose his shirt and his trousers without blinking, but when that underwear comes off, vulnerability becomes the new reality. He finds himself in a strange, unknown environment, and now his boys are dangerously unprotected. A small voice whispers, “You had better know what you’re doing, because at the moment this is not looking too good.”
The following three or four hours don’t exist in my personal memory. Promptly after losing my underwear an anesthesiologist placed an IV in my arm, administered a hypnotic—a drug that sends you into la la land—and that’s all I recall until I awoke in the recovery room. In days gone by anesthesia was a somewhat risky undertaking, and the awakening patient often realized that something unpleasant had transpired within about two seconds of regaining consciousness. That was when every four-letter word that patient knew was swiftly revealed to those in attendance. Awakening from anesthesia often meant severe pain, nausea, and an overall feeling that if death were an available alternative at the moment it might just be first choice. Fortunately the drugs used to knock patients out for surgery have improved remarkably, and even when those undesirable after effects are present we have some terrific antidotes.
My wife has since informed me that when I awoke in recovery I was doing quite well. I was chatting with her and the nurses and did not complain of any significant pain or other problem. You notice that I stated, “My wife has since informed me…” I have absolutely no recollection of anything that transpired during the time I was in the recovery room. Anesthesia has another interesting effect: it often induces retrograde amnesia. While the patient is often alert and able to offer clever quips immediately after awakening from surgery, come the next morning all of that will be wiped from his memory, like a hard drive gone bad.
Here I offer another tip for family members and friends of you surgical candidates out there. Don’t tell the post-operative patient anything important while he or she is in recovery; it will be totally forgotten by the next morning. Of course if there is something you wish to reveal to alleviate long-standing guilt—darling, only two of our children are actually yours—this would be a pretty good time to do so. The events of that entire day will in the future be at the minimum a blur and most likely completely irretrievable. Most humans consider this a good thing.
Soon I was transported into a lovely private room in the nearly brand new building of The World Renowned US Medical Center, (donated by a ridiculously rich World Renowned Arab Sheik—your oil dollars at work). Things were looking good. I had survived surgery without major incident, I was safely in place in my room on the Urology floor with plenty of experienced personnel available, and my beautiful and loving wife was by my side.
And then I saw IT. I had known IT was coming. Prior to surgery involving any part of the urinary tract, they put IT in, usually just after the patient is put to sleep in the operating room. That is a blessed thing, to have IT placed while unconscious. IT is a urinary catheter, also known as a Foley catheter, named for the physician from Minnesota who introduced the latex balloon catheter in the 1930s. During and following urinary tract surgery, it is important to monitor urine production by the kidneys and to identify possible bleeding. The Foley catheter is placed into the bladder via the urethra, which is quite short in women, and woefully long in men (well, not all men.) IT must travel a far greater distance in a man than in a woman, and for that reason the former experiences far more discomfort than the latter. For this women should cheer. I cannot begin to tell you how many of my women patients have complained to me about mammography and childbirth, that no man would ever tolerate either. Well, ladies, here is where you get at least a bit of revenge.
Remember that underwear I sadly left behind prior to surgery? You can’t wear a pair with IT extending from your guy. While a man is at rest, the Foley is not much of a problem. But get up and start walking, and that rubber fella yanks and tugs and makes for a most unpleasant stroll. Of course after surgery movement is critical to avoid blood clots in the legs and to work your lungs. My wife is a former nurse. “Up, up,” she insisted, like Santa commanding his reindeer. “You need to walk.”
“Great, you stick one of these things up your privates and you walk,” was the best retort I could muster in my compromised state. Even if she did it wouldn’t have felt like mine, she being a woman. By the way, this is the same woman who during my first colonoscopy years earlier stood watch over all 140 pounds of me and insisted I drink every last drop of the four gallons of the colon-cleansing antifreeze. When I had completed about 90% of that horrific concoction she said, in her sternest Nurse Ratchet demeanor, “You need to drink all of it.”
“Darling,” I replied, “we prescribe the same volume to 250 pound men as to someone like me. I’m pretty sure I’m good.” I like to keep this one at the ready in my marital armamentarium whenever she insists she knows what’s best for me.
I was comforted by the knowledge that all I was experiencing was temporary. Within 48 hours IT would be gone, I would be waving farewell to The World Renowned US Medical Center, and my life would be right back on track. So I took it all in stride, behaved admirably with nurses and staff, and awaited the appearance of my doctor. He arrived in the early evening replete with his entourage of residents. During the course of my medical career I have known many surgeons. This guy was clearly a prince. Not only was he very skilled—frankly, for the patient this is all that matters—but also humble, kind, and caring. I liked him so much that for a moment I forgot why he was in my room and just started chatting. This was followed by the words every patient longs to hear: “Everything went well, you did great, there were no complications.”
Maybe it was the waning effects of the anesthesia, maybe it was seeing my beautiful wife smiling at me, or perhaps it was the way the words hit me. My eyes welled up with tears, and I felt enormously grateful. I thanked him, told him how fortunate I was to have him as my surgeon, and then thanked him yet again. He told me that I might be able to be discharged tomorrow afternoon but more likely I would stay two nights and then head home on Thursday. We made a bit more small talk, then shook hands and he and his minions departed, promising me as he exited that he would check in on me tomorrow.
It was very difficult to find a comfortable sleeping position. Exiting my left lower abdomen was a drain that was connected to a plastic bottle. When major abdominal surgery is performed, there is almost always some bleeding and some “weeping” of the tissues that have been disturbed. Leaving the blood and fluid to collect is like having a small standing pool of water in the summer. Just as that static water is prime real estate for mosquitoes, bacteria love warm bloody collections. At the conclusion of the operation the surgeon places a drain in the area where the fluid is most likely to collect—the lowest area when the patient is supine—and this acts like a track and encourages the fluid to follow straight out of the body into a collecting chamber. Not only did I have the foreign body exiting my abdomen but I was also sporting a plastic “purse” tethered to my hospital gown. And of course I still had IT.
We tend to think of a hospital as a refuge for the ill and wounded, a place where in addition to the miraculous drugs and procedures that are available, peace and quiet are not only encouraged but also required. Think again. A more apt analogy would be to imagine a patient in a bed just in front of the checkout at Walmart on Black Friday—at 1 am just after the doors have opened. Bright lights blazing, people scurrying to and fro, doors opening and slamming shut, chatter everywhere; this is the modern hospital.
It’s 2 am. I have slept little if any. There is a knock on the door, but before I can respond in strolls a housekeeper. To collect trash. At least she was quick. Eventually I doze off, but not for long. At 4 am another knock, another uninvited entrance. “I’m here to take blood. Can I turn on the light?” I could have recited a soliloquy from Hamlet; she wasn’t listening anyway. I force a smile and offer my right arm. She checks my name and ID—they are really good at this at The World Renowned US Medical Center—and proceeds to stab me with her apparatus. This too is brief. Thankfully she extinguishes the interrogation lights as she exits.
At 5 :30 am I am awakened by the sound of the door opening; no knock this time. “Hi, Dr. Klein. How are you?” The entourage of residents has arrived. “Your lab work is fine,” the senior resident informs me. He glances at my drain and IT. “Looking good. Dr. Allaf will be here later today to see you.” He smiles, they all turn and leave. It all happened so fast that when reviewing the night’s events later I wasn’t even sure they had actually been there. My wife, who had spent the night on the sofa in my room, assured me that they had. She also confirmed all of the other intrusions, which I was pretty sure were not hallucinations but after anesthesia you never know.
Wednesday, post operative day one, was essentially uneventful. One of my best friends, to whom we will refer as Dr. B, is a urologic surgeon in Florida, and he had warned me to go very slowly with my diet following surgery. “They will try to feed you the next day. Don’t do it. Go slowly,” he urged me. He knew from experience that the bowel doesn’t take kindly to being pushed and prodded, even if it wasn’t the actual target of the surgery. When annoyed, it simply just stops functioning. “I am not going to tolerate this insult!” it proclaims, and pretty much nothing moves along and out, if you get what I mean. So I took his advice and only drank water and juice, not that I was hungry anyway. I watched some TV, spoke with my family and friends by phone, and took naps. I was alive and my surgery was behind me. Except for IT and some moderate pain, I was all right and very, very grateful.
Wednesday night was a repeat performance of Tuesday night. Lots of doors opening, lights flashing on and off, blood drawn, trash collected, and periodic visits from nurses to check that I was still alive and breathing. All I could think of was what daylight had in store. IT was going to be removed, and I was then going home! By 5:30 am I was alert and ready for the kids—the residents—to arrive and proclaim my freedom. Right on schedule there they were, barging in as if arriving at a fraternity party, pumped up and ready to rock. The senior resident checked my accouterments—drain purse, IT—proclaimed them all in excellent working order, and told me that discharge would be forthcoming later in the morning. He would send their PA—physician assistant—to remove my drain and IT would be removed.
“Hold on,” I said. “Can’t you pull my Foley now?” He looked at his underlings and then at me.
“Well, we are on rounds and have to get finished before heading into surgery,” he responded. I could see the wheels turning. My guess is that he knew that I knew that removing the Foley would take ten seconds, so his argument about delaying their appointed rounds really didn’t hold much water (excuse the pun.)
After a rapid evaluation of his situation—the fact that I was a physician and knew that there was really no reason he could not do as I asked—he smiled and said, “Sure.” He instructed one of the youngsters to fetch the catheter removal tray, a disposable item containing a syringe to remove the fluid in the balloon that kept IT from falling out, and some antiseptic materials. Since this was a urology floor, you couldn’t help but run into one of these trays within ten feet of any room. Within about a minute his gopher had returned, and soon after IT was out. The thought of kissing him did enter my mind, but I settled on a sincere “Thank You.”
IT was now where it belonged, at the bottom of the trash can last emptied by the joyous housekeeper who had visited me at 2 am to unburden me of garbage that she must have thought would otherwise have kept me anxious and awake. I hurried into the bathroom and cleaned up as best as possible. The anticipation was almost unbearable. Free from the limitation of locomotion that was IT, I bolted to the cabinet that housed the clothes I had worn on admission. In the bottom of the plastic bag emblazoned with the name of The World Renowned US Medical Center, I located the treasure—underwear. My unconscious was now playing “Joy To the World.” Don’t you marvel at the song you mysteriously find yourself humming that perfectly fits the situation? God has a fabulous sense of humor.
There was still the drain to be removed, that alien residing deep within and attached to my “purse”. In days of yore residents did everything for the patient. We started the IVs, drew the blood, placed and removed catheters and drains. There were no such things as Physician Assistants, IV Therapy Teams, Phlebotomy Teams, or any other teams. We were it, poorly paid, overworked, and perpetually exhausted. Frankly patients were not optimally served in this system, but we did learn a lot as young physicians that made us far better doctors down the road. The system has changed so that residents’ hours are restricted and supervision is far greater. One might assume this a good thing, but like just every other change that is implemented, there are positives and negatives. Today’s patients are in some ways better off under the new system, but we are producing a generation of physicians with limited skills and, for many but not all, a less than exceptional work ethic. Tomorrow’s patients will likely not fare as well.
I waited impatiently for the PA to arrive and pull my drain out. It wasn’t until just prior to her arrival that I thought about what this process might feel like. I have pulled drains from patients, but honestly I had been more concerned as a doctor-in-training with the success of this minor procedure than with what the patient actually experienced. After an hour she arrived and prepared the necessary items to remove the little fella.
“So what should I expect to feel?” I asked.
“Oh, not much I don’t think. But actually I’m not sure.” Oh well, I thought, I guess I’m about to learn something new.
After donning her gloves and cleaning my skin, she cut the sutures holding the drain in place and began to slowly pull the drain. Imagine that a snake is asleep inside your abdomen. Someone sneaks up on the guy and begins to extract him through a small hole. He awakens and decides he’s not quite ready to leave. Pain would not be an accurate description of what I felt. It was more weird and uncomfortable than painful. Thankfully it lasted only seconds, but I could summarize by saying I would not volunteer for this sensation on another occasion, and neither should you.
Like the snake in my abdomen, hospitals never seem anxious to let go of anything, and that includes patients. Extrication from a hospital is no small feat. Although both IT and my drain and purse were now history, I still had an IV that had to be removed. This takes about 3 seconds, but that doesn’t include the additional hour one often must wait to find a nurse who can do it.
I do not consider myself an unattractive man. Trouble is I have hair in places I could do without, while my head lies about 80% barren. I always just assumed that this was God’s payback for an ill-advised comment I made many years ago. When I was sixteen my sister, who has four years on me, was dating a completely bald guy. He came to our house to pick her up for a date one evening, and when he entered I had just completed a shower and my hair, quite full and long at the time, was in disarray. He caught a glimpse of me and asked, “What are you growing up there, a forest?” Without even a moment of consideration, my youthful mouth let loose the retort, “What are you growing, a parking lot?” And it was at that precise instant that I am certain that God decided to take the hair on my head and permanently move it to my back.
I share this personal information so that you can understand why any time a health care worker comes at me with adhesive tape I shudder. That adhesive will at some point have to be removed. Women reading this will know exactly what I mean. Eventually a nurse arrives and removes the IV and with it performs an uninvited waxing. I wince, but the knowledge that I am that much closer to freedom minimizes the discomfort. Finally, all paperwork completed, all tubes removed, I am escorted by wheelchair to the front door. My wife helps me up, and we make our way through the doors of The World Renowned US Medical Center, into the parking lot, and on our way. Once again my eyes become moist, and gratitude fills my heart.
By the time we arrive home it is late in the afternoon. I am tired, a bit weak, and in moderate pain, but all I can do is celebrate my homecoming. None of my children are home, but my dog is thrilled to see me, and I him. Dr. Allaf instructed me to take it very easy. He reminded me he had cut my left kidney in half only 48 hours previously, and it would be the polite thing to not tax the surgical site with excessive activity.
Sleep that night was difficult, for although my accessories had all been removed, I was still very sore and finding a comfortable position was a challenge. I did snooze on and off, and at about 5:30 am I awoke feeling fine and made my way to the bathroom. Like a man at a football game at halftime, I approached the toilet ready to empty a night’s worth of kidney work. Only nothing happened. I could not urinate. Instead a few drops of blood dripped into the toilet. My heart sank: I knew immediately what was happening.
I woke my wife. “I’m in urinary retention,” I told her, explaining that my bladder wouldn’t empty. “It’s because there is blood in my bladder causing irritation, so it won’t contract. I must be bleeding from my kidney.”
“What are you going to do,” she asked?
“Call Dr. Allaf, and I’m pretty sure we are about to head back to the hospital.” I reached Dr. Allaf on his cell phone. He agreed with my assessment and suggested I return to The World Renowned US Medical Center, a decision I had already made. About ten minutes into the trip, I began to experience a pain in my left side. Over the next several minutes the pain increased. My wife noticed my discomfort.
“What’s the matter?” she asked.
“I’m obstructed,” I answered. “I’m pretty sure that there are blood clots obstructing the urine outflow from the kidney.” I was upset because I knew what this meant. At the minimum, IT was returning, and for how long I couldn’t predict. Worse, this bleeding could be serious, requiring some intervention, maybe even another surgery. Only the increasing level of pain distracted me from visualizing what the near future might look like.
Upon arrival in the emergency department I explained my situation to a clerk who escorted me to a seat in front of an unmanned desk. She assured me that a nurse would soon arrive to speak with me. After fifteen minutes, no nurse had appeared. I was in a great deal of pain by this time, and my patience was wearing thin. Plus I knew that someone had dropped the ball—another benefit of being a physician and understanding how the system worked—so I got up and headed towards the back of the room until I encountered a nurse. I explained who I was and that no one had come to talk with me yet. This nurse was clearly savvy; I could see that she had rapidly reached the same conclusion as I that I had fallen through the cracks. She walked me back to my original seat, and asked me to wait just a moment while she procured my paper work. This she retrieved from the clerk who had earlier shuttled me to the unattended desk, and then in an unsubtle manner dressed her down for her incompetence. Within ten minutes my new best friend had completed my paperwork and escorted me through the ER to an examining room.
A urology resident had been dispatched to see me in the ER. Step number one was to relieve my bladder obstruction. Everyone has experienced that most unpleasant sensation of having to urinate and not being in a location to do so. This could be at a bar or a ball game, or in transit on a plane with the seat belt sign illuminated and humorless, cold-hearted aging flight attendants patrolling the aisle. Urinary retention—the inability to empty one’s bladder for mechanical reasons—is the granddaddy of that sensation. When I tell you that I could not wait to be reunited with IT I am not exaggerating.
Soon IT was in place, but despite my anticipation that I would immediately experience relief this did not occur. My perplexed expression was obvious. I had placed a good number of catheters in my time and urine almost always immediately flows through the catheter and into the collection bag. Not so for me. My bladder was traumatized, and it took a minute or two for things to get going. This delayed gratification would prove to be foreshadowing. Nothing would come easy for the next five days.
Enter Gerald. Gerald was a part-time emergency room nurse at The World Renowned US Medical Center, and it was my fate to have him as my first nurse in the ER. His full-time job was at a US government agency; nursing was merely a way to make some extra cash. I don’t mind a good cynic, but it is not a very endearing trait in a nurse, especially when one’s kidney is screaming. Gerald did not think much of The World Renowned US Medical Center, but he did enjoy golf. This we discussed in between my waves of pain and nausea. My discomfort did not deter Gerald’s non-stop conversing. On and on he went about his golf game, interrupted only by his snide comments about the Emergency Department of The World Renowned US Medical Center.
After about two hours in the ER, I was taken for a CT scan to identify the source of my pain and bleeding. Within seconds after my scan was concluded I could see the problem. My kidney was in fact full of blood that had clotted, and this was acting as a ball valve preventing the urine from passing from my kidney down the ureter and into my bladder. In effect I had a giant kidney stone, but this one was made of blood clots instead of calcium. The good news is that the body has an elegant system of dissolving clots, so this was a temporary situation. The bad news is that this elegant system takes a long time to work, like days. I wasn’t going home any time soon.
After a few hours Gerald informed my wife and me that there were currently no beds available on the urology floor of The World Renowned US Medical Center. This was not of great concern to me because it was only noon when he made this pronouncement, and I assumed that in a few more hours patients would be discharged and the situation would be rectified. Several additional hours passed, and Gerald, now nearing the end of his mercenary shift, added that it was not only urology that had no beds; The World Renowned US Medical Center was entirely full. Still, I was certain that eventually I would be moved to a room. Gerald didn’t agree. “Oh, you will be in the ER all night. This happens all of the time,” he added flippantly, as if they had simply run out of sprinkles to put on ice cream.
Gerald popped in periodically to check my vital signs, make sure my IV was running, and to inform us that still no bed was available. Other than that he was of no use. My pain had not been adequately managed; I should have insisted on more medication but really there was no one to ask. By 6 pm I urged my wife to leave and return home. Our dog needed attending, there was really nothing she could do to help me, and I did not want to worry about her leaving in the dark. Reluctantly she honored my request. Now it was just me, my bloody kidney, and IT.
At 11 pm, now fifteen hours after my arrival in the ER, a hospital supervisor entered my room. She apologized profusely that no bed was available anywhere in The World Renowned US Medical Center. The best they could do, she explained, was to move me to a room at the rear of the ER that sounded a lot like Purgatory. It wasn’t actually part of the ER, and yet it wasn’t an in-patient bed. I would be sharing a bathroom with another room; otherwise I would be by myself. Shortly after this conversation I was transported down a long corridor, out of the noise of the ER, to what appeared to be an almost abandoned section of the hospital. Here I was wheeled into a small room and transferred from my ER bed into a variant of a hospital room bed. A nurse checked my vital signs and told me to call if I needed help. The lights were dimmed, and soon I was alone.
My pain had not diminished, and lying in bed was not helping. After awhile I negotiated my IV and IT into manageable positions and stood, hoping this change in position might alleviate my pain. Standing alone in the darkness, now shivering in pain, I became acutely aware of my predicament. Some people routinely get the short end of the stick. Doctors all know who they are. Doctors are long-end-of-the-stick people. We do our best to be compassionate and empathetic, but we are well aware of the difference in station between we long-end-of-the-stick people and our short-end-of-the-stick patients. Now suddenly I was a short-end-of-the-stick patient uncertain of what lay ahead. Standing alone in the darkness, cold and shivering, it all seemed surreal. Once again tears had formed, and the heaving and heavy heart all humans at some moment in life experience made its presence felt. Nothing could be done at the moment; I had no options. I could not pull out my IV, shed IT, and waltz out of the hospital. I was stuck in this room, in this emergency department, in this hospital, with this pain.
I am fortunately not one to dwell on the unpleasant. My minute of self-pity was soon over. “Shake it off,” I urged myself, and immediately I imagined my dog wildly shaking to rid himself of the rain. I was reminded that, short of tragedy, most things in our ridiculous human lives are funny, especially in retrospect. I smiled, reminded yet again that life can be indescribably preposterous. My present scenario was all of that.
I returned to bed and dozed intermittently, periodically interrupted by the sound of my comrade in the adjoining room using the bathroom. From the pattern of the sound, I knew my “roommate” was male. How I envied him, standing like a man and voluntarily emptying his bladder, while I lay in bed like an infant, my effluent sucked out by gravity through the emasculating IT. Creating erudite sentences with words that no actual human would ever utter was at least a diversion.
Daylight inevitably brings optimism. It was Saturday morning; I had now been in the emergency department for almost twenty-four hours with hardly a visit by anyone in the past six. Finally a nurse arrived, checked my vital signs, and asked me if I would like some breakfast. “Any idea when a bed may be available?” I inquired. “Sorry, not yet,” she answered, then turned and exited the room, clearly in a hurry to attend to another marooned patient.
Another twelve hours passed before the good news arrived; a bed had opened on the urology floor. By my reaction you would think that I had just been upgraded to the Presidential Suite of a Hawaiian luxury hotel. As I was wheeled into my room—the same one I had left 48 hours earlier—those now familiar tears of gratitude reappeared. During my 36 hours in the ER I had been mostly alone, or under the care of the obnoxious and self-indulgent Gerald. The nurses here were well versed in the care of patients like me, and they could not have been kinder.
Since it was the weekend I had not expected to see Dr. Allaf, but late in the afternoon he entered my room. His news was not welcome. My creatinine—a measure of the kidneys’ ability to clear the blood of waste products—was rising, a sign that the obstruction of my kidney had not resolved. Of course I was not surprised nor did I need a blood test to inform me of my condition. My pain had not abated, indicating an ongoing obstruction. Dr. Allaf considered taking me to the operating room and placing a plastic tube—a stent—from my bladder into my kidney to allow the clot to pass. He was concerned that the pressure building up in the kidney could rupture the sutures that were holding my recently operated kidney together. All I could think of at that moment was another week with IT.
My heart sank. A stent, though effective, can be quite uncomfortable, and it would be in a while. It also meant two trips to the operating room, one to place the stent, the second to remove it. If Dr. Allaf were adamant about placing the stent I would have agreed; I had great trust in him. But I could see that he was not convinced of the best course, and that opened the door to discussion and some negotiation. He concurred that we could wait another day before making a decision on the stent. A bullet dodged, for now.
Once again I insisted that my wife leave during daylight hours. Although I enjoyed having her with me, there was little she could do for me despite her best intentions. My wife is never bored. Small needles are usually dexterously flying around a canvas, or she is reading, or making notes to organize some facet of her never-dull life. Still, being confined in a hospital room when all of your parts are in perfect working order can take its toll. As if she needed another wonderful trait, she has the patience of a gaggle of saints. Had I asked her to, she would have stayed day and night. When one is married to such a magnanimous person, it becomes difficult to be selfish; the contrast is obvious and embarrassing. So I sent her on her way and anticipated another night of pain, sweating, and nocturnal visitors.
All three arrived as predicted. I am not certain what caused it, but every night I was in the hospital I would awaken absolutely drenched in sweat. This was the cold kind of sweat, the variety that causes you to leap up as soon as you realize what has occurred and shiver violently like an infant stolen from the warmth of its incubator. My bed sheets were of course also soaked. I pushed the nurses call button. A mysterious voice replied, “Can I help you?”
“Yes, would you send a nurse in please?” is how I responded to the voice from the wall. That was my grown up, professional voice. It was generated by the most mature neurons in my highly evolved cerebral cortex, the ones that insist that as a grown man, a physician and father, I must maintain my composure, be polite, and suffer in at least relative silence. What the rest of me wanted to say was this: “I’m wet and freezing and I’m in so much f’ing pain and I hate this and I want to rip this damn thing out of my dick and pee like a man and get the hell out of here! So could you just send in the f’ing nurse, like now!”
Another tip from “Good Ideas for the Infirmed”, which is what I might call my next book. Being rude to nurses, or any medical personnel, is about as good an idea as yelling at the person behind the airport ticket counter when trying to get on another flight after yours was canceled. I take that back; it’s worse. Eventually the airport person will get you on a plane—maybe two days later, but at some point. When tethered to a tube or two, you really could use all the help you can get, and time is usually of the essence. What you’re shooting for is a scenario that when you hit that help button, the nurse on the other end thinks, “Oh, Mr. Smith needs help. That Mr. Smith is one fine person, so kind and grateful and polite and all. I love helping him. Gotta go right now.” In order to reach that station, you, the patient, need to actually be kind and grateful and polite. If you are an asshole and you hit that button the nurses on the other end, noticing from which room it emanated, might instead say to each other, “Do you hear anything? Me neither. So, what are you planning to do this weekend? It’s supposed to be lovely weather.”
I’m not nearly the saint my wife is, but I do try and be kind and grateful and polite, so within two minutes an angel—everyone called her Z—appeared at my door. I was a pitiful site. Standing, shivering, holding my IV pole, minimally clothed in one of The World Renowned US Medical Center’s finest patient gowns. Let’s digress for a moment and discuss hospital couture. This is one of those “we can put a man on the moon” moments. How is it that in this era of almost daily technological miracles hospitalized patients are still wearing what amounts to a candy wrapper? First of all, they are paper-thin; they would not keep an earthworm warm. They tie in a maximum of two places, assuming that the strings are still attached, which in my experience is a 50-50 proposition. If you have ever had the misfortune to get a hospital bill, you would be keenly aware that the freight for your stay is a number that would make Warren Buffet sit up and pay attention. Hospitals are not cheap. One in-patient day is five times the cost of staying in a suite overlooking the Mediterranean in Europe’s finest. At these prices male patients should be wearing Hugo Boss and the women Gucci or Chanel (depending on personal taste, of course.) Instead we dress patients like homeless people.
Z took one look at me, and instead of cringing, smiled. “Let’s get you fixed up.” First she negotiated my sopping hospital gown around my IV and replaced it with another clean, dry candy wrapper. She placed a clean sheet in the reclining chair that was next to my bed, seated me, and covered me with a warm blanket. Then she turned her attention to remaking my water-logged bed with fresh dry sheets. “You are still in pain, aren’t’ you?” I nodded. “I’ll be back in a minute.”
And she was, with fresh water and a pill. I am certain I thanked her at least a dozen times throughout this process. My appreciation was honest and palpable. Not for a moment did her smile leave her, not for a moment did she make me feel like she was doing me a favor, which of course she was. Wow, I thought, she gets it. And how fortunate am I that she does. I sat in the chair for a while, and eventually returned to bed to try and sleep. This time I was still awake when the nightly trash patrol arrived to save The World Renowned US Medical Center from being overrun with litter. Not that this mattered, because shortly after I was again visited by the phlebotomist. I merely extended my arm, confirmed that I was whoever she wanted me to be, and allowed her to pierce me yet again. After you have been poked and prodded over a certain threshold, it no longer matters how often this is. I suppose this is what happens to hostages; at some point they become inured to the abuse.
At 5:30 am the residents arrived. That blood that had been taken several hours earlier revealed that my creatinine, though still elevated, was stable, which indicated that no further damage was likely being done to my kidney. Dr. Allaf, they told me, was still contemplating the stent. He wanted to do a sonogram to check the degree of obstruction in my kidney, and this would be performed this morning. That made perfect sense to me. While the blood test would reflect the relative function of my kidneys, a sonogram would give us a look at how much clot was still present and reveal the degree of obstruction.
At about 9 am I was transported to the Radiology Department for the ultrasound of my kidneys. The technologist who would perform the exam greeted me. I thought I owed her full disclosure. Ultrasound is one of my specialties, and I was going to be paying careful attention to what was on the screen. About two minutes after she began she abruptly stopped and, in a rather concerned voice, said “Oh, my. I pulled out your IV!” And indeed she had. The IV that had been in a vein in my wrist was now dangling by its attached adhesive tape. That wasn’t nearly as much of an immediate concern as was the blood that was pouring forth from the now revealed puncture site. I grabbed a nearby sheet and began to press on my bleeding vein. In a minute it had stopped, but my designer gown and I were covered in blood.
The technologist was genuinely upset about what she had done. Poor thing; I felt badly for her. How embarrassing it must be for her, I said, to do this to a physician, and a radiologist no less. I was laughing, and it was abundantly clear that I was not angry and that she had nothing to worry about. I assured her that I had the bleeding well under control, so she set off in search of a nurse who could put me back together. Soon I was cleaned off, re-dressed, and ready to resume the sonogram. On the screen I could see that the clot remained in my kidney, but the degree of obstruction was not as bad as I had feared.
From the moment I left my room for the sonogram, my pain had been increasing. By now it was severe, on the order of 9 out of 10. The only possible way to relieve this pain would be by IV medication, and of course my IV was currently in the trash in the ultrasound room. I was therefore desperate for a new IV. Two nurses were present, one of them the nurse who had come to help me after my IV had been ripped from my arm. She graciously offered to replace my IV. It took several attempts—of course, carrying on the week’s theme—but eventually she was successful, and I took great solace in knowing that pain medication was now in my near future.
All I needed was to be transported back to my room, and believe me I could not wait for that to happen. My pain was barely tolerable. “We called for transportation,” the other nurse informed me, well aware of my impatience to get upstairs and get some pain relief. “Sometimes it takes awhile for them to come.”
It used to be that whoever was available to transport patients in a hospital did so. It could be a clerk, a nurse, even a resident, or the technician performing the test would come for the patient and then bring him back from where he came. Not anymore. Now we have a degree program for hospital transport. Only designated, certified, highly trained professionals are permitted to wheel patients around The World Renowned US Medical Center.
These folks are, I am sure, unionized, and they have a schedule to which they must adhere. Which means that you are about as likely to get someone to port you to and from your procedure in a timely manner as you are to catch a cab on a rainy day in November in midtown Manhattan. After twenty minutes of waiting and making small talk with the nurses—I actually offered one a job working for me—no highly trained transporter had arrived. One of the nurses—the one to whom I offered the job—could no longer stand seeing me in pain and took it upon herself to transport me back to my room, risking the wrath of the unions.
Janet was my nurse that Sunday afternoon, thank God. She had been a nurse for a good many years; this was one experienced woman. My pain was obvious, and needed something powerful right away. “The resident only ordered PO Dilaudid,” she informed me, clearly aware that this would not get the job done. “PO” means by mouth, and what I required was rapidly acting IV pain medication. If ever there was a time to play doctor, this was it. I picked up my phone and texted the following to Dr. Allaf’s cell phone. “Sorry to trouble you. Please, my pain is unbearable. Would you kindly have your resident write an order for IV Dilaudid as soon as possible? And throw in an IV anti-nausea drug as well if you would be so kind.” I wasn’t interested in trading the pain for intense nausea, a side effect of the pain medicine.
Janet stood by the electronic monitor in my room, attentively eyeing the screen. “I will know as soon as it is ordered.” Within three minutes—as Dave Barry would say I am not making this up—that order popped appeared on Janet’s screen. I can only imagine what transpired during those previous three minutes. Dr. Allaf saw my text, called his resident and perhaps said something like “Are you out of your mind, ordering him only PO Dilaudid? Get him IV Dilaudid now, please.” I am assuming the “please” was included, since Dr. Allaf is a great guy, but maybe not.
Janet had the medicine ready, and slowly pushed it into my IV. In seconds, I am in a place I have never been before. It is a place totally free of pain. I am floating and every cell of my body is at peace and in love. With eyes closed, I tell my wife, “Everyone should feel like this. I want to kiss the universe.” For the record it was not the drug-induced high that I was celebrating, but the delicious relief from overwhelming pain that I experienced in that blessed moment.
For the rest of the day the pain repeatedly returned, subsequently successfully crushed by more IV Dialudid. At day’s end the entourage of residents once again appeared. I filled them in on the latest events. They were about to hustle out to the next leg on their end of day rounds, but I stopped them. “I want to talk to you guys for a second.” Perplexed looks abounded. The senior resident spoke for the group. “Sure, what do you need?”
“Actually I don’t need anything,” I replied. “I’d like to share something with you. When you’re a resident you want to see the best, coolest cases. You surgeons can’t wait to get into the operating room, the more the better. But the number and quality of cases that you see is not what is going to determine the success of your career. And by that I mean what you actually get from your career. Do you know where the real joy comes from in medicine? It comes from knowing that you made a difference in a patient’s life. And believe it or not most often that doesn’t come from making the brilliant diagnosis or performing the elegant surgery. It comes from listening to the patient, from making sure you take the time to hear his concerns. When a patient begins with, ‘I know you’re in a hurry but…’ instead of agreeing, try replying with ‘No, I have time. What do you want to talk about?’ and take a seat at the foot of his bed. And then you listen, and nod, and don’t say anything until he is done. Most of the time he isn’t asking for anything specific. He just wants someone to hear his concerns, even those unrelated to his exact medical condition, and to know that you, his doctor, is interested in him, all of him. And then when he looks up and says, ‘I can’t tell you how much I appreciate you taking the time to talk with me’ you know that you just did something very special for that person. That is the real joy. It’s what I call the golden handcuffs of medicine; it’s what keeps you coming back day after day.”
All three were silent for a few moments. The senior resident, already four years into his training, then said, “You know, Dr. Klein, no one ever talks like this to us. Thank you.” I knew he meant it.
Night once again brought drenching sweats, and the nurses delivered with more wonderful care that I responded to with more grateful tears. Both the trash and phlebotomy women did not disappoint and arrived on schedule. Monday morning, however, brought something new. I experienced a wave of pain on my affected side, but instead of continuing unrelentingly, after a short time it suddenly subsided. A few minutes later I noticed something solid within my catheter. Clot. My large kidney blood clot was breaking up; my body was doing its job! Over the course of the next few hours this pattern was repeated—relatively brief wave of intense pain, followed by the appearance of more clot in the catheter. This was major progress; now, I knew, it was only a matter of time before this ordeal would end. I wouldn’t need a stent, of that I was now certain. For the remainder of the day I was just short of euphoric. Every new wave of pain was followed by the appearance of another remnant in my catheter. Considering how large the clot appeared on my imaging studies and the size of the pieces appearing in my tube, this would not be a rapid process. But who cared? Not me; I was a lean, mean clot-busting machine.
Now that my situation was improving, I new that I had to get up and move about more than I had been doing. Of course there was still IT to contend with. Even worse than the significant discomfort I felt every time I attempted locomotion was the sick feeling I had just seeing IT exit my hospital gown. IT was saying, “You are old. You are feeble.” Every pair of eyes that sees you struggling to walk a yard thinks, ‘That poor geezer.’” My brain and body have both insisted that despite my chronological years I am still quite young. I can easily do 60-70 pushups at a time. I have an eleven year-old son with whom I throw a baseball and shoot baskets. I can zip down a mountain on skis as fast as I could twenty years ago. Yet here was this thing, IT, declaring that all a mirage. Walking at two miles per year, clinging to an IV pole, and IT; honestly, I felt pathetic.
Monday night was yet another repeat of sweats, kind nurses, trash chick and phlebotomist, and little rest. Soon enough it was early morning and the residents appeared. Only this was a different group with whom I was unacquainted. And then it hit me—it was July 2nd. At almost all major US teaching hospitals, new residents begin training the first week of July. Which means that the least experienced medical personnel roam the halls of US teaching hospitals just after the summer solstice. Those residents now in charge of your care know pretty much nothing about you. They are likely to ask you the same inane questions you heard on the first day of admission, and have pretty much no idea what has transpired up until that moment that they first greeted you. One of my colleagues called me in the hospital that afternoon to see how I was feeling. His first statement was, “I can’t believe you are in a teaching hospital. Do you realize what day this is?”
For those patients arriving in the Emergency Department during those early July days, the situation is even more dire. Here you find complete no-nothings, eager but totally ignorant medical amateurs. I am not trying to be harsh or unkind. My first moment as a medical intern, the term previously used for rank novices now euphemistically referred to as first-year residents, was Saturday night in the very busy emergency room of The George Washington University Hospital in Washington, DC. In that era the ER was staffed with three interns and one second-year resident. We had essentially no grown-up supervision, unless you count the poor nurses to whom the responsibility of keeping patients from harm fell. Those initial days were terrifying for us interns, and should have been for those unsuspecting patients who entered those doors. It is a testimony to the resiliency of the human body that more patients weren’t accidentally terminated by the ignorance of the mostly inept medical intern over the years. Unfortunately some patients were, which is why ultimately the system was permanently changed. Now experienced doctors carefully oversee the rookies.
By Tuesday morning more clots had come and gone, and the frequency of pain had significantly diminished. Dr. B and I had exchanged texts, and we concurred that I should not leave the hospital until completely free of pain and we are assured that the entire clot has resolved. Soon after the residents arrived and enthusiastically announced that since my blood tests had continued to improve I could be discharged today. I smiled, and then informed them that that was not what was going to happen. Instead we were going to continue to observe the clot breakup, and if all went well I would go home tomorrow. I am sure, I added, that Dr. Allaf would be fine with this plan. About an hour later the PA entered my room. She too proclaimed the good news: I was doing so well that I could go home! Tomorrow, I informed her, tomorrow.
At about 10:30 Dr. Allaf arrived. His residents had informed him of my desire to remain another day, and he graciously agreed. Five minutes after he left the room, I glanced down at my catheter. Other than for the occasional clot that had been passing over the prior couple of days, it had been clear. Instead what I now saw was a dark, granular material pouring forth from my kidney. Immediately I knew what had transpired. The large clot that had been impeding the flow from my kidney had been broken down enough that, like a dam bursting, all of the junk that had been retained behind it in my kidney was now freed. While the uninformed might have glanced at the ugly material in my catheter and cringed, I was elated.
Another ultrasound of my kidney was ordered. I knew it was unnecessary, but I could only be so obnoxious in managing my own care. Ultrasound exams are perfectly safe, as long as the technologist doesn’t rip out your IV during the study. The ultrasound proved completely normal, and the afternoon check of my blood corroborated the improved function.
At that point I could probably have safely been discharged. Though I longed for IT to be removed and the return of my underwear, on balance I decided that, considering the exploits that landed me back here five days ago, the smart move was to be certain all was well before I checked out. My lifeline, my great friend Dr. B, had recommended this course of action and I was not about to disagree with his sage advice.
By 5 am I was up and ready for the residents to appear. All that stood between my underwear and me was removal of the Foley. At 5:30 they arrived, confirmed that my final blood test was normal and that I could be discharged. Since they had to continue on their early morning rounds the new senior resident wanted me to wait for the PA to arrive later that morning to remove the catheter. Here we go again, I thought, just like my initial admission; another resident who doesn’t want to take the minute or so required to get this damn IT out of me. I looked at him and said in the nicest way I could, “Please take this out now. It only takes a few moments and I will be so grateful.”
Like I said, removing a Foley catheter should take ten seconds. The water filling the balloon that holds it in place in the bladder is removed with a syringe—five seconds—and the Foley withdrawn—five seconds. Only that is not what occurred. Part one went fine, but as he pulled the catheter it got stuck. I am not kidding, it got stuck just at the end. As you can imagine, this did not feel very good. The only reason I think I did not scream is because I was shocked that this had happened. The resident turned and looked at his younger colleagues.
“Every so often the balloon doesn’t deflate completely. In that case, you have to rotate the catheter to get it out.” He then turned his attention to me. “This might hurt a bit.” No kidding, I thought. IT is taking a final whack at me. As advertised, the final step in removal was quite unpleasant, but that damn thing finally released me. IT and I had achieved permanent separation.
As soon as the entourage left I literally leapt out of the chair and headed for the bathroom. Without IT I was free to shower, and of course that was followed by the ceremony of the return of the underwear. I felt like the person who had entered The World Renowned US Medical Center one week ago. Tears yet again flowed.
For only a single moment during my hospital course did I worry that this episode could end badly. That was the day when my pain was most severe, my blood tests worsening, my blood pressure rising, and the immediate future unclear. For the most part I was certain that I would recover, that the pain was temporary, and that I would eventually once again be ministering to patients instead of being on the receiving end of medical care.
Perhaps it is my training as a physician that produces those occasions when I feel more observer than participant. At several points in my hospitalization, even the grimmest, I could not help but marvel and ultimately laugh at the ridiculous plight of we humans. These vessels we have been given in which to conduct our earthly mission are flawed in goofy ways. As elegant as our human bodies are, they are fraught with serious deficiencies, and clearly not intended to last forever. Nevertheless, these deficiencies produce no limit of humor. Much of it is dark humor, but as they say, dark humor is better than no humor at all.
Our job as humans is to seek out and nourish relationships; they are the core of life. It happens that many of the most important relationships are only temporary, such as those between nurse and patient. During my stay at The World Renowned US Medical Center I was fortunate to be cared for by one excellent nurse after another. Those nurses lived their vows. As I stood in pain, shivering to my bones during the darkest moments of my stay, there they were, kind, patient, and caring. I recall thinking; this is how I always want to be with my patients.
After my return to the real world I called General Stafford and related all that had transpired, from my initial detection of my tumor through to the end of my hospitalization. “That is amazing. You saved your own life,” he told me. “Actually, General, you saved my life,” I replied. “If you had not asked me to speak with that legislative aide, I may not have discovered my tumor for years. So as it turns out we are in a manner linked forever.” Who would have ever believed that the sixteen-year-old boy watching in awe as Apollo 10 circled the moon would one day find his life intertwined with the astronaut flying that spacecraft?
I should not be surprised; that is precisely how the world works. The simplest decisions and choices initiate a cascade of events that results in the most unpredictable outcomes down the road of space and time. It’s not the events themselves with which we should be preoccupied. Instead we should focus on the relationships that present themselves along our journey. That is where the magic resides.
I have shared my story with many of my patients. I do so because it makes me more like them. I have been there, I tell them; I understand. When I then add that all will end well they believe me. Though for some the end will be sooner than they may wish, all will end well as long as they have spent the time they are here in life celebrating their family, their friends, and each of the strangers with whom a life-enhancing relationship awaits.
I had one bad week; nothing more. Eventually I did get my underwear back, and with it a chance to help more people just as Dr. Allaf and his nurses so gently helped me. That’s exactly what I plan to do.
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