So can you
We physicians are often asked to predict the future, but we should always be very careful when we do so, as there are some things we simply don't understand. (Cheyne-Stokes is an abnormal pattern of respiration that may—or may not—presage death.)
Solemnly, I walked out of his room
and told his family he was going to die, very soon.
He was Cheyne-Stoking, no output
from hepatorenal syndrome, deeply comatose.
They understood his drinking
had finally caught up with him.
Twenty-five years later, he and I met on Main Street.
He said he just got back from Vegas,
offered me some gold coins,
and showed me his beloved pit bull sitting placidly
in his even more beloved Pontiac convertible.
I asked about his wife and kids. "Good," he said,
"I'm a lucky man."
He hadn't had a drink since that day
I played know-it-all doctor.
Now I go the other way—
responding, when asked,
"Yes, you're going to die, some day."
Everybody does. I think.
Aging and death routinely try to uncouple love stories. They rarely succeed.
Her room is compact, a condensation:
the well-loved farmhouse, to the renovated condo,
to this "pleasant and well-appointed room."
Home now to her books, books she's read or written.
Home now to her giraffes; there's seven of them, you know.
Home now to her bed, her chair, her bureau.
Home now mostly to her pictures—
kids, grandkids, a few of her.
But mainly pictures of him—with his seaman's hat,
his welcome smile and his arm
around her, touching her, holding her.
He is everywhere in this compact room,
here with her, as he would want to be,
as she wants him to be. She understands.
With the peace of a good Quaker, she accepts.
She says only, with a deep, unseen tear,
"He was a nifty guy."
The brevity of a laconic New Englander's dialect can mask the depth of emotion and portent behind it. (A lacunar infarct is a stroke caused by a blockage in one of the tiny arteries that supplies blood to the brain's deepest structures.)
Some little artery, no bigger than the thread
you use to sew your cardinals on a throw pillow,
just got smaller.
So you have a spot on a CT scan,
a lacunar infarct. Exotic, like it's from far away.
But it's not, and your right side doesn't move.
And you're angry?
You get pneumonia
or heart failure—we're not sure which,
so we treat both. You get better.
But while you were sicker they asked you,
"If your heart stops, do you want us to restart it?"
You said, "Ask my doctor, he knows."
So I hold your hand,
or you hold mine.
I paint the picture straight and ask,
"Is this what you want?"
You look at me and see cardinals,
bake sales, the West Swanzey Library,
your brother, and more cardinals.
We physicians must be lifelong learners. But there are some things—like how to mute your feelings when you decide to stop keeping someone alive at the end of a "code"—that some of us never quite master.
The insertion of vastus medialis oblique,
the differential diagnosis of hypercalcemia,
the progression of joules to defibrillate,
the side effects of the little white pill,
and, of course, the Krebs cycle current
disguised as the cytochrome P450 system.
Taking the time to reflect—
that's all, just reflect
about the person around
the heart you're shocking . . .
All, and infinitely more, need to be learned,
used, forgotten, relearned, used, forgotten, relearned.
It all gets jangled, passed, related, and guessed at.
But eventually forgotten and, maybe, relearned
just before it's needed again, just before.
After forty years, some of it comes easier.
A lot of it comes harder, but the learner's not as bright.
Most of it now is evidence-based, and that's good.
But there's one concept this man has never mastered,
despite all the protocols and too much experience:
When the shocked heart has had enough,
and the deprived brain has extended its magic four minutes,
but the person's body is still warm—
if only because of our bottled oxygen,
pumped around by our sweaty, doubled hands—
while a nurse marks the time for the recorder,
how do you call a code without
getting that bottomless, hollow chill?
Physicians are taught early on to keep patient interactions on a purely professional plane and never to let things get too personal. Later on, many of us feel bothersome questions tugging at our white coats: Should we? Can we?
Talking about life and death is part of the profession.
You get used to it, at least the life part.
"Congratulations, you're pregnant!"
"You have a beautiful baby girl!"
"Your son is growing perfectly!"
The other part? Not so much getting used to it,
practice sure isn't making perfect.
You try to be honest and direct,
yet compassionate and considerate.
Sure, you try. But who knows if you are?
You've learned to stick to the facts, honor honesty,
hold a hand to offer compassion,
look in an eye to connect.
You've learned these things and you try.
You've decided not to say,
"Look, we're both going to die,
and I can't face it,
but it's important that you do."
You've decided not to say it,
but you know it,
just like you know that talking about life and death
is part of the profession.
Toms has practiced family medicine in New Hampshire for over 30 years, retiring in 2005 as medical director of Dartmouth-Hitchcock Keene; the same year, he was named New Hampshire Physician of the Year by the New Hampshire Hospital Association. He still practices part-time in rural Maine, where he enjoys hearing his patients' stories.
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