Reflection

by Lara Jirmanus, SOM ’09

Honorable Mention 2008 Gerald F. Berlin Creative Writing Award

It was 11AM and I was admitting my first patient, a 65 year-old woman with 20 medical problems and possible bowel obstruction. My pager went off, but I didn’t look at it immediately. I scrolled through the medical history, hoping to make sense of my patient’s diagnosis.

No one ever pages me. I looked at the number. My mother’s cell phone. What could it be? I’m busy. I sat down to type the patient’s med list. Thirty medications, which I had to put into alphabetical order to keep them all straight. Having finished her HPI, it was time for a break. I rose and walked to a phone at a desk in the ED. My mother picked up. “What’s going on?” I said, trying to keep the edge out of my voice. The last time she called she was wondering if I was OK because I wasn’t answering my phone, which was charging in the call room.

“Thank God you called back,” my mother said, “I’ve been calling you all morning. Your dad had chest pain.” The rest of the words all ran into each other, as though they weren’t even spoken. “He went to the emergency room at Mass General. He’s in the cath lab.” Cath lab. The words echoed in my ears. The beeping and bustle in the ER faded into the background. “What?” I said, in disbelief. “Did he have an EKG?” knowing full well the answer. I’d been poring over guidelines for R/O chest pain for attending rounds. “He was tossing and turning all night and had some discomfort and some pain in his arm,” said my mother. “Why didn’t you tell me this morning?”

Of all coincidences, I had slept that night at my parents’ house, having stopped to pick up my cell phone. In the morning, my father made coffee as I rushed about gathering my things for work. My father recounted his checkup with the doctor the previous day. “He’s really mad at me for not taking niacin and aspirin,” my dad said. He asked me if I was taking them and I said no. So he asked me, “Why do you keep coming to see me if you’re not going to do what I say?” He told me I should stop listening to my wife. My mother interjected, “Maybe it’s time we find a new doctor.”

My parent’s arguments with their PCP have been going on for years, ever since he prescribed hormone replacement therapy for my mother. After insisting for years that she take it, he did the unthinkable. He told my mother that it wasn’t her decision alone and suggested that my father should, “Make her take it.” After the Women’s Health Initiative study data was released showing increased risk for cardiovascular events in women on HRT, you can only imagine what my parents thought of their doctor, of doctors in general and of “clinical guidelines” and “expert opinion.” That morning, as I left the house, I thought to myself – I really need to show my dad to calculate his Framingham risk score, look up some articles about lipoprotein(a). (His is very high, believed to be an independent risk factor for cardiovascular disease). I would tell him, your risk of having a heart attack in the next ten years is ___. Is that a risk you can live with? No rush. I’d do it next week. There’s time. No history of coronary artery disease in the family and he’s the youngest of three brothers.

“Why didn’t he say something to me?” I asked my mother. “I would have sent him straight to the ER.” “He didn’t say anything this morning. He was burping and he said he felt like he had a lot of gas in his chest. We thought he had a stomach bug.” I hang up and tell my team. My resident picks up the phone. “Operator, could you please connect me with the ER at MGH?” “Hi,” he says, “I’m checking on one of my patients.” Surely enough, he’s forwarded to the cath lab. “Oh, ok, he’s in recovery. He’s stable, not intubated.”

All these words, they’re for books, for the wards, for morning report. Not for my dad. My resident starts to draw me the familiar picture: the heart with coronary vessels winding around. My eyes lose focus on the fuzzy dot he draws in one of the arteries. “His occlusion was in the LAD, not in the left main, which is a good thing. They put in two stents. An unstable plaque ruptured which triggers an inflammatory response…” Dr. Cuenod’s explanation plays back in my head from last fall’s cardiology class. How can this be happening? I walk back to my car, taking deep breaths. He’s stable, I say to myself.

In the cath lab. How many patients did my team rule out for MI in my first month at university? They stopped giving them to me because it was no longer a “good learning experience.” Most were sent home straight from the ED. The woman with two gold rings on every finger and a migraine, who argued with my resident about having a coffee less than 12 hours before her stress test. “But I don’t understand why I can’t have it,” she said, raising the cup to her lips. She had finished half the cup by the time we got it away from her. Or the business man who stopped into the ED on his way back from the airport. He commutes to Florida twice a week for work. His gold chain glinted pale against his orange chest, too tan from UV tables.” Do you smoke? Drink alcohol? How much?” He would make cell phone calls between rounds of questioning. “I’ll write this one up,” said my intern. “I don’t think he had an MI. It’ll take two seconds.” Looking at the patient’s drug list: hydrochlorothiazide, Lipitor, lisinopril, aspirin, nitrates for chest pain. Did my dad look like he was having an MI?

In the CCU we see him, looking a little weak and faded, but normal. My eyes drift to the telemetry monitor; the ST elevation is still obvious. The cardiologist said he was lying on the cath table chatting, joking around. “We didn’t believe it until we injected the dye,” he said. “90% occlusion of his left anterior descending artery. He apologized to us for not taking his medicines.” “Sorry,” my dad said. “I should have taken the niacin and aspirin.”

Now he’s better, home and bored to be sitting around. In the cardiac step down unit, every time we would go, there were at least two or three other visitors. My dad offered them Jordan almonds that a friend brought. In Lebanon, he explained, it’s customary to bring the patient sweets, so that even if they can’t have them, they can offer to visitors. Everyone sits, talking about cholesterol and hypertension. “I can’t believe it,” says Susan, who used to work as a medical interpreter. “You’re so healthy and you eat healthy and exercise.” My dad tells them about lipoprotein(a) and his confrontational visit with his PCP. “I had been feeling a little more tired when I exercised lately, and the morning of my appointment I was having a little discomfort. Maybe I would have gotten an EKG if I had told him, but I was just so annoyed with him that I didn’t mention it.”

I’ll never forget those words. Perhaps an EKG, which the lab never did, although my father has one once a year, would have shown changes. Perhaps at least my father would have left with instructions to chew an aspirin in case of chest pain before calling an ambulance. Maybe we’re so lucky that it didn’t matter. As a doctor, it seems you have to be both good cop and bad cop. A good listener, understanding and meeting your patients where they’re at. At the same time pushing them to where you’d like them to be.

On the wards we often speak of the pancreatic cancer patient in 703 or the PE in 514. As we order our Troponins, LFTs, CBCs and BMPs, and chase down patients with “good findings” to share on attending rounds, it is too easy to lose sight of what illness is to a patient and their loved ones. Illness: the point at which we encounter our own mortalness. When we are forced to realize that we are not merely a mind and a heart and a memory and spirit, but contained within a set of miraculous organs, that pump, secrete, and contract in concert. And that become rusty, with cricks and clogs as the decades pass. And that eventually fail. To become a pile of flesh, perhaps to rest on a cold metal table in an anatomy lab. To be approached by a curious set of first years, who make their first cut with the scalpel, eager to see what is inside.