My First Patient Was A Mouse

I didn't think much of it at the time.

Most physicians can trace back and recall their first patient.  For some, it is a clinical encounter the third or fourth year of medical school.  The more creative may point to their cadaver during first year anatomy and nod knowingly.  My first patient was a mouse.   Or shall I say a group of them?

My freshman year of college, I volunteered in the lab of a prominent endocrinologist and studied a new drug to reverse the course of type 1 diabetes.  We monitored genetically bred, non obese, diabetic mice.  Every day we would reach into their cage and grab them as they scurried about.  Then we would rub their bellies inducing urination, swab the urine, and test for glucose. The unlucky creatures with a positive urine test needed to have blood drawn.  The thing about mice is that they don't have obvious vessels like you and I.  In order to get a drop of blood, we had two choices: either cut a portion of the tail or tap the choroidal plexus behind the eye.  The latter approach, while more brutal, was less maiming.

I would take a swab and dip it in ether.  The swab would be applied to the mouses nose inducing anesthesia.  The tough part, while applying pressure to the orbit causing the globe to pop out of the socket, I would slip a pipette behind the eye and turn until blood shot up the tube.  Then, if we were lucky, the mouse would wake up.  If not, we used our fingers to compress the chest performing mouse CPR.  Those mice proven to have diabetes would be randomized to two separate groups.  One would get the experimental injection while the other would get placebo.

I passed many days and weekends alone in the lab.  One sleepy Saturday,  I approached a mouse in preparation for a blood draw.  Mice can be slippery creatures.  The technique most favored was to grab them by the scruff of the neck with the thumb and forefinger, and hold the back tightly with the base of the hand.   So I thrust forward like I had done dozens of times.  I got a good hold, and flipped the mouse around to face me.  But something went terribly wrong.  I must have grabbed too high, or maybe too roughly.  The mouse's body quivered and then shuddered in such and odd and frightening manner.  I reflexively released as the mouse fell to the table.  Dead.  With horror, I realized that I accidentally snapped it's neck.   I will never forget the feeling of life passing so quickly and unexpectedly in my hands.

I occasionally think about this as I watch family members cradle their loved ones in those passing moments before death.  Do they feel the shudder?  Do they experience revulsion or relief?

And I sometimes have fevered dreams about that mouse.  When I toss and turn, unable to sleep because of the crushing pressure of some clinical decision or another.  That poor creature.

That poor creature who succumbed under the weight of my thick, clumsy hands.

Sadness On The Side

The calls came simultaneously.  One from the hospital and the other from a nursing home.  Two deaths separated by fractions of a second.  My heart swelled.  For a moment.  The pile of papers on the desk softly whispered.  My mobile howled jealously vying for my fragile attention.   I could feel the emotion drain as I turned back to the task at hand.  Unexpectedly, my mind wandered back to the wedding in California.

It was a spectacle.  Pre-ceremony hors d'oeuvres with sushi stations and Kabobs.  An open bar long before the utterance of the first I do.  The wedding party bespectacled in gowns and tuxedos danced down the isle as the gala began.  I felt the joy, in every corner of the room, soak the participants in a  humid haze.  It was heavy but far from suffocating.

I held my wife's hand as first the groom and then the bride sauntered down the isle.  The groom paced the full length but then circled back as his bride reached the middle section.  They walked together to meet the Rabbi.  My wife glanced in my direction and saw the tears welling in my eyes.  She looked quizzically before turning back to the ceremony.  I was far from surprised.  

I have been crying a lot lately.  At weddings, during movies, or while watching television  It's something that has grown exponentially over the years.  The barriers of my heart have become weak and the tide crashes into the breakers and spills shockingly on the barren land below.

I have lost control.  And I know exactly why.

It's just that I see so many awful things.  My daily menu consists of death and destruction with a healthy serving of sadness on the side.  I swallow these whole, rarely having the time or energy to chew properly.  Yet all that is pushed down must eventually be digested.  I no longer mourn, for after all these years mourning would have morphed from a hobby to a full time profession.  I neither grit my teeth nor curse a deity that often seems indifferent to the suffering of us poor plodding humans.

Instead I cry.  When it's safe. When the joy becomes overwhelming.

Ordinary People

Cheryl loved to dance.  There wasn't a time in our house when the the kids weren't jumping up and down on the furniture, the radio blasting, and her body swaying in rhythm.  Ironically, we were dancing when it happened.  It was her fortieth birthday.  The kids laughed and clapped as I dipped her dramatically and she sprung back into my arms.  And then she crumpled.  Tony, my youngest, giggled hysterically thinking it was a ruse.  I clutched at her lifeless body, all muscle tone was lost.

It was the emergency room physician who first used the word "stroke".  But what does a plumber know of such things?  In my experience you could always replace the damaged or diseased part.  I clung to this naive worldview as Cheryl was transferred to the ICU.  Tony and Lisa alternated between collaborating and arguing as I held vigil at her bedside.  And we waited.

Everyday the neurosurgeon came in with worse news.  First there was bleeding.  Then an increase in brain pressure.  The nurses whispered about hospice, but no one had the fortitude to talk of such things openly.  I wouldn't have listened anyway.  How does one give up on their lover, partner, friend?  If there is one chance in a million, wouldn't you take it?

The conference room was full of doctors and social workers.  Tony and Lisa stayed outside in the waiting area and played with legos.  The neurosurgeon was severe and agile, a man of action.  He described the procedure to remove part of the skull to relieve the pressure.  The Internist was mousy and meek. He used numbers and percentages.  He assured that it would be OK to do nothing, to let nature takes it's course.  I visualized Cheryl's brain like a drain clogged and stuffed to the point of bursting.  I imagined reaching with my tools and clearing the debris.  I decided to let the neurosurgeon have at it.

The years that followed were difficult.  Cheryl didn't die, but she never recovered either.  And each fork in the road was met with another gut wrenching decision.  Tracheostomy, feeding tube, nursing home.  Her brain severely damaged by swelling and blood, her recovery was tortuous and incomplete.

She did improve.  The tracheostomy tube was removed.  She is able to move her eyes and verbalize some.  The most coherent thing she does is cry.  Everyday, in the nursing home, by herself, she cries.  She is unable to lift her hands to wipe away the tears nor does she have the brain power to negotiate the psychological torture of her daily existence. She just knows that something is wrong.  And it cannot be fixed.

Lisa and Tony are teenagers now.  They try to visit from time to time but they are in the process of building their own lives.  They are stuck in the chasm between childhood and adult.  Their invalid mother is a constant reminder that life can be horrifying.

And I wonder if I made the right decision that day in the conference room.  Maybe we would have been better off if Cheryl died quietly in that ICU.  Maybe she would have suffered less.  But I try not to think about such things too often.

Because Cheryl, Tony, Lisa and I, we're just ordinary people.

We don't always know which way to go.

Parenting And Helplessness

Years later, I now wonder if I overstepped my boundaries.

Nancy was a pleasure to have as a patient.  A physician's assistant in her early twenties, we often chatted amiably during visits.  Our conversations randomly ambled between personal and professional topics.  She recently married and was looking forward to having children.  Her gynecologic history was complicated and after a period of months of unsuccessful attempts to get pregnant, she visited a local infertility specialist.

Although the workup was completely normal, one of her blood tests, while technically in range, was deemed "subpar".  Her obstetrician sent me a letter asking if I would monitor levels and adjust medications.  Appointments were made, labs were drawn, and a few months later a pregnancy test came back positive.

Nancy was overjoyed.  Every so often I would receive a note from her gynecologist documenting her progress.  Ultrasounds were normal.  A litany of screening tests uncovered no abnormalities.  Everything was perfect, or so I thought.

One morning I was surprised to find Nancy sitting in my exam room crestfallen, on the verge of tears.  Her gynecologist was struggling with her levels.  Her previously "subpar" blood test was closer to range, but still had not met the magic number that her infertility specialist had decreed optimal.  With her medical training skills honed from education, Nancy had searched out a bevy of papers suggesting a correlation between low normal values and poor pregnancy outcomes.  Thirty weeks into gestation, She felt like she was in crisis.

While I was unconvinced by the tenuous connection in the literature Nancy produced for me, I couldn't help but feel a lightning bolt rush through my own insides.  How many times had I struggled with these same fears with my own children?  How many times had I painstakingly deliberated over my little ones ad nauseum.  To give vitamins or not?  To treat with antibiotics or wait longer?  Every decision dissected and second guessed.  Each time feeling so sure that my failure to decide correctly would mar my child for a lifetime.

My eyes glistened as I told Nancy that having a child was like ripping your heart out of your chest and then leaving it in the open unprotected by the strong bony architecture of your rib cage.  That to procreate was to feel an uncertain type of helplessness that is unmatched by other realms of human experience.  She will try to control almost every part of her babies existence and fail over and over again.  And yet most likely, despite all her foibles, her child will be more perfect than she ever imagined.

Nancy, I explained, was experiencing the first pangs of parenthood.

We decided on a treatment plan.  We scheduled a follow up visit one week later.  And then she left the office.

I never saw Nancy again.  She cancelled all future appointments

Years later, I wonder how things went.

I often imagine her holding her baby lovingly.

Pressing Questions

Picture your shoulders thrusting forward as you slink into the nursing home or hospital at some ungodly hour in the morning.  Day after day, year after year, your gait adjusts to the facade of the foreboding colossus.  You become boxy, structural.  Familiarity has affected you.

It's not just the hospital, but the patients of course.  Being a physician is just like any other human being, just magnified.   You start with a basic unadorned body of armor.  Certain things penetrate: the first cry of a baby as he leaves the womb.  Others splatter and stain but you don't dare let them in: the swoosh of blood as it spurts out of a ruptured a-v fistula, the screams of fear, and the ever-present sobs of the mourning.  The outsides may become disorderly and unkempt, but the insides remain pristine.  Or so you think.

Patients come and go.  They either die or move away or decide they no longer want to receive care from you.  Hospitals open and close.  You move your office.  There is much transience.  The faces fade and the circumstances become hazy.  But the detritus remains.  You may forget the specifics but your exterior has been marred.  Your armor adorned.

Until the day you realize that you never really had any armor in the first place.  Just porous skin.  Now faded and bruised, you carry these marks with you. That which you relied on for protection has inevitably become a sieve.  Your insides are now also untidy.

And you may find yourself walking through the mall on occasional Saturday mornings with your family. Your children weaving through the isles and ducking under wayward clothes.  Your wife leafing through the discount racks in the corner.  Your phone hangs from your ear as you answer yet another phone call.  You stop mid orders to look at yourself in a full length mirror.  And you wonder if the reflection is really you anymore or some stranger.

The pain only lasts for a moment, and then you turn your attention back to the phone and answer-

whatever pressing question is being posed to you.

For Those Of You Who Worry About Me

Ruth was problematic.  Well into her seventies, her body may have dulled but her tongue was sharper than ever.  And she used it to lash me with complaint after complaint.  If it wasn't her knees, it was her ankles.  If it wasn't her ankles, it was her hips.  I battled the impossible month after month, year after year.  Our interactions left a bitter taste in my mouth.  Nothing makes a physician feel more impotent than the stubborn problems that refuse to bend under our practiced hands.

I am fairly experienced with complex medical issues.  I have never shied away from diagnostic challenges.  But I have to admit that Ruth seemed to push my buttons just so.  I started to dread our visits.  I winced every time her name came up on my schedule.

I am not proud of this.  The covenant between doctor and patient is sacred.   Neither a patient's attitude nor my inability to solve her problems is an adequate excuse for such feelings.  

It all changed instantaneously.  I was walking lazily through the Botanic Gardens with my family one weekend when I spied Ruth a few hundred yards away in the Rose Garden.  She was surrounded by children and grandchildren.  The young ones teased and coaxed as Ruth hopped back and forth with her walker.  Her laughter wafted effortlessly through the air.  She was alive and animated.  Her gait straightened, her limbs moved, and her face was alight with joy.  This was not the same crotchety woman whose visits I had grown to loathe.  I stared awestruck for a few moments before moving on.  

A week later, Ruth hobbled into my office with none of the aforementioned spring in her step.  After making small talk, I mentioned that I had seen her from a distance at the gardens.  I talked of how alive she was amongst her children and grandchildren.  How her laughter caressed each brow, patted each back approvingly.  I saw no evidence of a body crippled by arthritis.

I could see Ruth appraising as I spoke.  She was waiting for me to get to the point.  Eventually I stumbled through my thoughts out loud.  I wondered why I had never seen such joy in the office.  Although I am only familiar with a fraction of my patient's lives, I usually have a distinct feeling for who they are.

As Ruth replied, I could see the the amusement in her countenance at being asked such an absurd question.

Joy?  Meh.  You expect me to be joyful at the doctor's office?  This is where I go to complain about my knees?

Her eyes sparkled and I nodded with a more profound understanding of our relationship.

And so it is with my writing.

The Space Between Sickness And Death

There is much to deplore in our medical system.  Atrocities abound in the dark recesses of hospital wards, the over packed waiting rooms of outpatient offices, and the algorithmic hum of insurance claim denials.  Yet time and again, the most vile of of insults are hurled at one setting in particular.  I'm talking of the place cursed by emergency room physicians when admitting yet another poor soul with a sacral ulcer, a place spoken of by patients and families in the most hushed and fearful of terms.

I am talking of the modern day nursing home.

The allegations of abuse and neglect abound.  The New York Times is littered with stories and editorials claiming inappropriate use of medications.  The view of nursing home owners is a bunch of fat cats, deceiving our elderly and neglecting the flesh in favor of the all important bank account biopsy.  And no doubt, as with any reputation, some of this is true.

Nursing homes endure, however,  because there is no other setting for such patients.  Long after the hospital has discharged and the family has gone home, someone has to take responsibility for our most downtrodden: the poor, the frail, and those maimed by disease.  The extraordinary complexity of the average nursing home patient has leaped forward over the last few decades.  The staff pivot from the average knee replacement rehabilitation to a paraplegic with a stage four pressure ulcer, TPN, and no understanding of the meaning of a polst form or DNR designation.

Our society has chosen to see ultimate darkness in this place it so desperately needs.   Yet, if we are searching for humanity, we must crawl into the places that no light is willing to shine.  We must wade through the morass and stench of human depravity.  Down here in the space between sickness and death you will find us. On our knees.

CNAs, nurses, social workers, administrators, dietitians, therapists, and yes physicians.

Singing, crying, laughing, and comforting.

Perhaps holding your loved one's hand.