A Two Way Street

As I approached the room, the nurse stormed out with an exasperated look on her face. Half way to the computer bank, she turned back to warn me:

I wouldn't get too close if I were you. She kicked the CNA in the chest

I entered the room to find Myrna pinned to the bed by her middle aged son. Russian curses spewed from her mouth intermixed with deeply accented English. Her legs kicked and her arms tried to flail against human flesh. The fatigue on her son's face showed as he let her go and sprung back to stand beside me.

Myrna was delirious. Her brain encumbered by plaques and tangles was unable to stave off the ill effects of fever and dehydration. Her usually calm demeanor was replaced by demonic screaming and unwieldy thrashing. Her ninety year old body was suddenly strong and agile.

Myrna looked up at us from the bed like a tiger ready to pounce. Her eyes rested on her son's face and then moved in my direction. My muscles tensed reflexively awaiting the possible onslaught. Her face softened.

The baby girl. How's the baby girl?

And then she smiled and looked at me knowingly as if we shared an intimate secret that no one else was aware of.

Even through the thick foliage of delirium,

she remembered.

*

I reclined in the chair and placed my legs on the desk in front of me. Just one more patient before lunch, and then I was done. My wife was thirty eight weeks pregnant and I looked forward to another weekend of peace before the new baby complicated our quiet lives.

My cell phone began to buzz and ring loudly. I almost fell out of my seat as I yanked my legs off the desk and dove into my pocket. Moments later, I listened as my wife spoke quickly on the other end of the line.

The ultrasound showed a problem. The doctor wanted her in the obstetrics ward immediately to be induced. My wife's voice was calm but firm.

Come home now!

I threw my lab coat on the chair and grabbed my jacket. I ran down the hall with one arm pulled through the sleeve and the other dangling out. As I passed my office manager, I spit out directions to cancel my last appointment and clear the next week.

The secretary and medical assistants huddled in the doorway and wished me good luck as I flew out of the office onto the landing, and jumped down the stairs in groupings of two. When I arrived at the bottom, I bumped into Myrna and her son who were making their way up to the office for an appointment.

They looked at me questioningly. I turned briefly and exhaled an explanation as I gasped for breath. Myrna shook her head and smiled. Even with her deep accent, I caught her words while racing out the door and into the parking lot.

It will be OK!

And it was.

Four years later, this memory came back to me as I sat with Myrna in her hospital room. Although her sensorium had not completely cleared, she was calm now. In time her fever would break and her mind would return.

*

I often marvel at how as a physician I am present during critical moments in my patients lives. I witness birth and death. I fight alongside them when it is time to fight, and console them when it's time to stop.

But every once in awhile a patient bears witness to one of my moments. And it is only then that true intimacy occurs.

Because between Myrna and I,

it was a two way street.

Hippocrates Or Hypocrite; Let's Make A Deal

I never said I was perfect. Nor do I feel that even on my best days I approach such a pristine state. Of course there are appearances. My pressed gray lab coat and buttoned down shirt contrast your suit, jeans, or sweat pants.

The roles and expectations are set in a frigid stone of familiarity. I will point, prognosticate, and occasionally shame you. You will listen, cower, and shake your head in agreement.

Often my voice will be strong and confident. For one who has never smoked, it is easy to rail about the evils of tobacco. No longer having the time or taste for alcohol, convictions will drip convincingly from my lips.

But other times, I will squirm and struggle to keep my voice steady. I will tell you that three hundred pounds is too much, yet secretly I lust for the jelly donut waiting in the break room. Have I never medicated with food?

I counsel on exercise, but my brand new running shoes have not yet left the closet.

If you only knew my addiction. The secret I carry in my belly.

I'm strung out. Strung out on stress like the rest of my physician colleagues. I imbibe it first thing in the morning with bleary eyes and queasy belly. I inhale it on quick breaks in back allies between patients and hospital rounds. I chew it, and hock the disgusting byproducts into a used coke can during late night phone calls.

Would my own foibles and humility strengthen the conversation? Would it help you to know that I struggle also? Could we become comrades instead of teacher and student?

More importantly, could I convince you that between horrendous and perfect there is a place called "good enough"? Because I feel fairly certain that if you exercise a little more and eat a little less, things will be better. For my part, I'll work on the stress.

Do we have a deal?

In Praise Of Mothers

I cradled my son's miniature body in my hands. Only moments old, he looked up with large glassy eyes. He was so alert, so perfect. I carried him over to the bedside. The obstetrician worked on the afterbirth as my wife waited patiently to hold her child.

At the time, it hadn't sunken in yet how much our solitary lives were changing. The nurses swept the baby away for routine testing and measuring. I settled into the chair and reclined for a few minutes before the the first signs of morning.

I didn't wake up for hours. Overwhelmed and exhausted, my body stumbled into deep sleep. My dreams were vivid and startling. And they brought back memories locked away and guarded with a key.

*

Any student rotating through the obstetrics department can tell you the stories. Every academic center has them. At my hospital, it was the cardiothoracic surgeon whose wife was delivering her third child and had an amniotic embolism. My attending shook as he told me how he heard the screams for help coming from the delivery room.

When you hear a guy like that, an experienced surgeon who has seen just about everything, yell with panic in his voice...

The attending stopped and looked up as if trying to question the Divine himself. After a long pause, he turned his attention back to me and changed the subject. I later found out that the poor woman was rushed to the operating room and her chest was cracked. It was futile.

I couldn't shake the image of an unfazable surgeon walking into his home alone with a new baby to face his other two children.

*

During my pediatrics rotation, as a student, I held a little girl in my arms in much the same way as I would eventually hold my own child. She was a few months old when her father brought her into the pediatrics clinic. He stared at the ground lifelessly as I examined his daughter. Occasionally he would grunt in response to my questions.

The first thing I noticed was that unlike most of the Hispanic baby girls brought into the clinic, her ears were unpierced. I unsuccessfully tried to question, but my pigeon Spanish failed me. I wondered why her father came to the clinic alone.

As I flipped through the chart the answers became clear.

The mother died during childbirth.

*

Last week, my wife was out of town and left me alone with the children. Every morning, I would wake up early before the kids started to stir in their beds.

Later, I sat with my four year old daughter and stared blankly at a closet full of clothes. We both looked at each other and started to giggle. I agonized over finding a suitable outfit. When we were done, I stood in front of the mirror with her small brush and hair clips.

After multiple failed attempts, I reached into the drawer and pulled out a head band. My daughter guided my hands as we affixed it properly. She looked appraisingly at my reflection in the mirror and spoke softly.

A good thing we have mommy!

If only she knew how simple hair and clothes are compared to everything else.

Yes. Good thing we have mommy.

Jordan Grumet Interviews Himself

Q: Thank you for agreeing to this interview. Before we start, I just wanted to say that your much more handsome in person than I expected.

A: Ya, I get that alot!

Q: Um...OK. Moving on. I notice that you write a new blog post on most days. How are you so prolific?

A: I have been writing my whole life. As a child I was greatly impacted by the death of my father, and growing up with a learning disability. Living through these experiences made me think deeply about my surroundings. I learned to search for the profound in every day life.

I categorized my thoughts, one by one, in the recesses of my brain. The actually placing pen to paper (hand to keyboard if you will) only occurred later as I developed the requisite vocabulary to do justice to my observations.

I try not to think too much about my blog posts, otherwise I may stifle the creativity that bubbles up.

Q: Taken as a whole, what is your blog about? What are the major themes?

A: If you asked me this question a few years ago, I would have said that my blog is a love letter to my patients. As I grow wiser, I realize that it is more accurately a love letter to my father.

When my father (a prominent oncologist) died, I was seven years old. As silly as it sounds, I spent a great deal of my childhood and young adult years trying to forgive myself for his death. Even though I knew I wasn't responsible for his aneurysm, I struggled with issues of being worthy of love.

As I read my own writing, I'm struck by the parallels. I fight to be protect my patients and lead them through the dying process, much in the way I wish I could have done for my father.

Q: I have noticed that you can be a harsh critic of yourself as well as other health care providers.

A: As with any love letter, My words are filled with angst, self deprecation, and remorse. I pine for the unrecoverable loss. My father is never coming back.

When I'm critical of other physicians, I am also criticizing myself and the foibles of our profession.

Q: So if this blog centers around personal issues and your father, why make it public? Why Facebook and Twitter?

I think there's value in the conversation. Although my inner creative process may stem from personal issues, the themes of my writing have broader applicability. Through my blog I attempt to record the epic battle fought by physicians between maintaining their humanity and protecting themselves from the atrocities of everyday practice.

We are both flawed and scared, as well as brilliant and steadfast. Physicians bleed when they are cut, just like everybody else.

If we don't let the public know who we are, how will we ever move toward equality and intimacy?

Q: So your saying that the doctor-patient relationship needs to be a two way street.

A: Exactly, I couldn't have said it better myself. As health care reform progresses, there will be a power struggle as resources become scarce. The sooner we open the door to our patients, the better we will survive the tumultuous future.

We need to build a partnership based on trust and common understanding.

Q: Any last thoughts before we end this interview?

A: No, other then to say that I enjoyed this conversation immensely. You really are superb!

Q: Thank You.

For Just About Everything Else

The sound of squeaking shoes and huffing ventilators filled my ears as I sat to type at the desk in the ICU. I was lucky to steal the only remaining station from a nurse who had left her chair to give report.

The nurses were dispersed in groups of two huddling around computers and signing out to each other. The ancient ritual of the changing of shift had modernized by technological necessity. Quiet voices recounted patient histories and recent lab tests. Occasionally my ears would perk up when a nurse placed special emphasis and her voice catapulted above the hum of the crowd.

A middle aged woman stood with her back to me with tattered blue scrubs and a stance of authority. She spoke melodically with occasional stops and starts. The young woman receiving her soliloquy was petite and outfitted in pink. Her scrubs were freshly pressed and free of biologic spatter or remnants of a hastily eaten meal.

I couldn't help but listen to the conversation as blue scrubs spoke.

Mr. Slip presented to his local pharmacy clinic with chest pain and shortness of breath.

I almost fell out of my chair. Who in their right mind would go to a "quickie" clinic with such complaints? I imagined the chaos as an ambulance pulled up to the local pharmacy. I craned my head to listen closely as blue scrubs continued.

An EKG was done at the clinic and was noted to be abnormal. So the patient was directed to the ER.

Again I was incredulous. They do EKG's at these places? Are they capable of interpreting them? I imagined a sign in bright colors with a beautiful, young, athletic woman smiling back at me.

We now do EKG's. Get one today at your yearly physical in the pharmacy department. By the way, did we mention we sell aspirin?

Pink scrubs looked as confused as I. Although she didn't interrupt her senior partner, her lips pursed and she flipped curls of hair out of her face in mock frustration. Blue scrubs was not finished:

After returning home to walk the dog, the patient arrived in the ER and was found to have S-T elevations in leads II, III, AVF. His blood pressure on admission was 80/50.

She went on to describe the rest of the sordid hospital stay. By the time I finished my own charting, my head was swimming. How did we get to this place?

It's like I always tell my patients:

If you have a medical problem that will go away on it's own without intervention, go to a pharmacy clinic.

For just about everything else,

see me.

The League Of Custodial Healers

For the first six months at the hospital, Leandro try to avoid The LOCH business. It was a new job and he desperately needed the money to support his wife and baby. But when the League of Custodial Healers approached a second time, he found himself sitting in a small room in the bowels of the facility with a group of serious looking environmental service consultants (or that's what they called themselves).

The leader was an elderly gentleman with a thick creole accent. He learned the Voodoo art during his first assignment at Charity hospital in New Orleans. Since then, he had taught thousands of custodial assistants the refined art of patient healing. His eyes became large and hands moved in an animated sweeping motion as he described to the group the ancient technique.

For centuries, doctors and nurses felt that the surgeries and medicines they provided were curing their patients, but the truth was an underground group of custodial healers was actually saving the day. They would sneak into the room and perform their sweeping rituals before it was too late.

At this point the old man grabbed his broom tightly and looked out at the crowd.

Why do you think so many people die in the ICU? It's because we have limited access.

He then placed his broom on the floor and demonstrated the ten cardinal techniques and their appropriate application. Leandro scribbled on a scrap of progress note paper as the demonstration continued. The presentation ended with the circular method. This method, only for the most dyer situations, began with a twisting motion in the middle of the room, and worked its way out to the far corners.

*

Although Leandro was skeptical, he honed his skills late at night in dark hallways of the hospital where patients slept soundly or were to ill to notice the lowly janitor cleaning their room. With time and practice, his skills improved.

And low and behold, the majority of the patients got better. They awoke from comas. They withstood chemotherapy. They conquered pneumonia.

Six months later, Leandro had perfected his technique. Each morning he would round on his recently treated patients before signing out of the night shift and going home to his family. He felt invigorated and connected. The patients and doctors may not know about the important service he was delivering, but he could live with that.

At the end of his shift, he tucked his trusty broom under his coat and left the hospital. He couldn't leave such a valuable and powerful tool sitting around for just anyone to use!

*

Upon arriving home one morning, Leandro found his wife cowering in bed. She had been vomiting and having diarrhea all night, and the baby was at his mother in laws. When Leandro looked down at his ailing wife, his clinical skills took over. Her face was pale and her skin was dry. He put his hand on her head and felt her temperature. She was hot! His intuition told him something was very wrong.

Leandro panicked. Even after all he had seen in the last six months, he packed her into the car and brought her to the doctor. When they arrived, they sat in the waiting room for what seemed like hours.

Eventually they were ushered back to the examining room. The doctor walked in and without introducing himself, began asking questions. He sat with his head buried in a lap top computer and his eyes never left the screen.

After a hasty examination, the doctor declared that his wife had a viral gastroenteritis that would resolve over the next few days. Leandro couldn't believe his ears. He started to explain that his wife had never gotten sick like this before.

The doctor looked at Leandro, and then up at the clock above his head. He was already an hour behind and had to return to the hospital to do rounds. He could either take the time to explain to the agitated man and his wife, or he could give them a prescription to placate them.

*

Leandro took the prescription to the pharmacy and ushered his wife back home to bed. He gave her the first dose, and then waited till she fell asleep. When the room was absolutely quiet, he snuck into the closet and pulled out his trusty broom.

He knew that this was a situation which called for the circular technique. As his wife snored in the background, Leandro performed the centuries old ritual. He stopped when he had successfully cleared each corner of the room.

Five hours later his wife awoke refreshed and feeling healthy again. Although she praised the doctor and antibiotic, Leandro knew what was really responsible for his wife's miraculous recovery.

After all, both Leandro and the doctor had their own form of medical Voodoo.

But at the end of the day, Leandro's method had one major advantage over the physicians.

At least the floor got cleaned.

Dignity Transcends

Leslie was the kind of person who made both men and women's heads turn as she walked down the hallway. Her back arched forward with perfect posture as she waited for me to enter the exam room. She stood, using one hand she parted the blond curls that fell in front of her face, and extended the other towards me in greeting.

I sat comfortably at the desk and opened my computer in preparation to start the physical. Leslie swayed back and forth in her chair slowly, and I sensed that something was bothering her.

Because she was a new patient, we chatted about her current health and past medical problems. I asked gentle probing questions to tease out the source of her discomfort. Although I had finished all the requisite social and family history, I still found myself searching

I opened the cabinet above the desk and pulled out a gown in preparation for the physical exam. At the sight of the white flimsy covering, Leslie's face became a bright shade of pink, and she turned in embarrassment. I was surprised by this kind of reaction from such a strong, confident appearing woman.

Is something wrong?

Leslie turn to face me again, and paused as she mentally rehearsed the next sentence.

You see Dr Grumet...I thought you were a woman....and I didn't shave my...

Her words trailed off as we both started to laugh. I offered her an appointment with my female partner, but instead she decided to return and finish the exam the next week when she was better prepared for the visit.

I sat in my office and giggled as I looked out the window and watched Leslie gracefully lower herself into the driver seat of her car.

And then I remembered something.

*

The morning rhythm of the ICU greeted my ears as I walked through the doors. The sound of shuffling feet, blowing ventilators, and beeping machines formed a raucous chorus. I stopped at the computer bank and looked at my patients labs and vitals.

She was much to young to be in this setting. Her twenty five year old body was stronger and more resilient then the average ICU patient. But the effects of chemo had taken their tole. Her immune system damaged and short handed, couldn't fight off the bacteria that plunged into her respiratory system.

Things were looking up. The chemo had finished. The ventilator was removed and life was beginning again. A bed was ready in the step down unit and hopefully she would go home soon. We chatted for a few moments before I started my examination. The lungs were clear; the heart was normal.

As I went to examine the legs for edema, my patient threw back her covers to reveal newly manicured toes with a bold shade of red polish. I looked up to the head of the bed to see her smiling.

She had been waiting all morning to spring this on me.

*

It becomes very easy in medicine to shun vanity. We looked past the dirty, unkempt, disease ridden bodies of our patients as a matter of course. We somehow picture ourselves too much above the fray to stoop to such banality.

But one thing I've learned from my patients is that dignity transcends sickness and health. That caught in the middle of a health care system that focuses on depersonalization, it takes courage to maintain ownership.

These women were trying to remind me that they are not just patients.

They are people: flawed, vain, courageous, and awe inspiring.