Call 3 - Ode to the Tapia
So I got a call at about 1:30 AM. I had been asleep a little over an
hour. The request was for pain medication, so I got up after a moment of
trying to clear my mind. I climbed out of the top bunk, got my shoes on,
discovering that I hadn’t untied my right shoe when taking it off,
forced my foot in as a result, put on my coat, and emerged out of the room, into the fluorescence of the
ward.
I pulled my cross-cover lists out of my pocket and
checked names. The name didn’t appear on any of my four creased sheets.
I walked to the back of the ward and checked names on the board. His
name wasn’t there. I walked to the front half of the ward, and found his
name, on a blue label, indicating he was an Oncology patient – not one
of mine. I told the nurse he wasn’t one of mine, that he was Onc’s.
There was no apology for waking me up, but I understood.
As I started to head back to the call room, she
started to get the operator on the line to find out who was covering for
Onc. I paused, then turned around, knowing my intern and senior
colleague was about to paged. “Wait,” I said, “Don’t page him. I’ll
check him out, and just wake him up.” She hung up the phone.
The gentleman was having substernal chest pain. He
had ecg leads on for telemetry, as well as 12-lead ECG leads on his
chest. He said he was having shortness of breath too; he wasn’t sure if
the oxygen had been turned down. I checked the O2, and found
that it was at two liters. The pain had been steadily growing for a few
hours, and was at about 7 out of ten now. Not knowing the patient’s
history – something that I would have had available if he had been my
cross-cover patient – I went to the call room, and woke my intern.
We talked about it a few minutes, weighing whether
he just needed pain medication or investigation of a cardiac process.
The patient had a bronchoscopy that day, which was a point in favor of
just pain meds. He also had atrial fibrillation after the bronch today,
a point in favor of doing an ecg at least. There were other risk
factors. That’s what I argued for, and my intern agreed.
I got the ECG going, and B.T. interviewed the
patient, eliciting more detail than I had in a way that his months of
intensive experience would enable. The ECG was unchanged from the post-bronchoscopy
version. The patient was in a-fib, but not having an ischemic cardiac event.
Steadied with that, B.T. prescribed a now dose of a pain medication, and
we were done.
Back to the call room. I climbed up the frame of
the foot of the bunk beds, and laid my face down on the pillows,
foregoing the blankets. I tucked my pager into my right hand, my thumb
on the green button, and had my phone tucked in the space under my neck.
I willed my neck muscles to relax. I imagined my head getting heavier.
But sleep wouldn’t come.
In the darkness I thought that a diagnosis is like
an unlit room. You uncover a little information, and the room gets dimly
lit. You just make out shapes. Maybe there’s a cancer up against the
wall, but you can’t make out the details of its form until the lights
are turned on brighter. You do some tests. Is it malignant or benign?
Where is it, exactly? The lights get brighter. You get a biopsy. You
discover the cell type. The lights are on now. Does it have a genotype
pattern that tells you more? Does it have receptors that are amenable to
a monoclonal antibody that can be introduced and used as a weapon
against it? The lights are really getting there now.
Of course this whole time, I’m not sleeping a bit.
I played a little more with this idea, thinking
that a differential diagnosis is a house of darkened rooms, and each
test sheds light within, giving clarity about the
structures that lie within each. This went on in less formed thoughts
until I tired of the machinations.
My thoughts shifted to what I would say at
graduation. What could I possibly say that would have meaning to my
classmates, who are as bright a bunch of beings as I’ve ever had the
privilege to work with? What could I say that would inspire my peers?
What could I say that wouldn’t sound too much like the trite optimism of
a novice when heard by the seasoned veterans that will be seated behind
me on the stage? What would be real and substantial? I thought I would
lead with my heart.
I’ve been holding my own, moving along feebly in
some ways, with little blips of splendor here and there, but nothing
compared to my bright- lighted classmates. I go with my strength, and
my strength is my heart. So that is where I may start. Lead with my
heart. It has served me well thus far, and most importantly, it has
served my patient’s well, I believe.
The people we are serving are sick. All of us know
what it’s like to have allergies, or a persistent stuffy nose, or a
sting or a bite, or some other little inconvenience that alters our
reality that makes us uncomfortable, and just a smidge unhappier than
we’d like. Our patient’s have real illness. They’re really sick, and
that’s an important thing to remember. With rare exceptions, they’re
pain is real. We may not be able to perceive it, but they certainly can.
Don’t forget that. Don’t discount that. Lead with that.
I lost the thread there, and decided to get up. I
rounded the ward and all was quite on both the backside and the front.
Two nurses were watching videos on computers, their earbuds in place. I
wandered over to the Tinsley service, and found other Medicine
colleagues doing their thing.
As expected, there was Patrick Tapia, among the
best and the brightest of my classmates, wearing his tie at two in the
morning, consistent in his infraction on my sensibilities of comfort. We
laughed at that.
And I wandered the halls some more, wishing for
sleep.
