"A Humbling Apprenticeship"

A Humbling Apprenticeship

“OK, Mrs. Evnoy, now I’m just going to quickly ask you a few questions about your social life… uh, um… its things that I, that we,  have to ask every patient.”

“Well, that’s fine.”

“Great, so Mrs. Evnoy, you mentioned you have a husband. Are you currently sexually active?”

I straightened my back in my rolling stool and tilted an ear to her response, making an attempt to demonstrate my deep concern for her health. I may have even furrowed an eyebrow, not sure.  I had watched my instructor enter and exit this same routine numerous times, and I myself had practiced it on simulated patients- but never on a real patient. As I made my entry into the same sexual history routine I had practiced over the previous month, I wondered if I would always remember this moment.  It was my first day of my first Community Week. This week was meant to be one of many ‘firsts’ for medical students; first time meeting a real patient with real diseases, first time learning as an apprentice in a real clinic, and first time obtaining a real patient history.  I had initiated one of my first rites of passage to becoming a physician. I extended my arms to readjust my sleeves and discretely brushed the knot of my tie with the back of my hands to make sure it was still in place. I wanted to make sure my mental image of this moment was perfect if I would be remembering it forever.

“Now, Mrs. Evnoy…” A knock on the door interrupted my moment.

“Justin, Dr. Burch wants you in the ER immediately.”

That’s fine, I’m sure he has something interesting for me to see. Plus, I would have time to further straighten myself up.

“I’m sorry ma’am, I’ll be right back to finish with you.”

I walked straight to the ER, speeding up until I was just fast enough to where the air passing by me pushed up the tail of my white coat behind me just like I had seen other doctor’s coats do; this was also the first time I was able to try out my white coat. Halfway to the ER, I noticed a lone middle aged woman sitting just in my periphery, causing me to again straighten my back and subconsciously give just a bit of extra air to my coat tail. This was my first fast walk to the ER, and I think part of me wanted to give her, whoever she was, the false impression that I was actually needed in the ER, and that I actually had some necessary knowledge to impart on whatever scene was taking place behind the thick blue double doors. I noticed her look up at me, again in my periphery, but I wasn’t sure how to look back.

After busting through the emergency room’s double doors, I quickly understood that my assigned position was against the wall. Dr. Burch was busy performing chest compressions while Dr. Daniels was administering some type of intravenous medicine to the motionless and naked body on the bed. Four nurses encircled the bed, each darting towards the bed at different times to hand the doctors needles, plug up tubes, unplug other tubes, and at times briefly relieve Dr. Burch from his compressions. One of the nurses stepped towards me to explain the situation.

“This guy just retired from his banking job in Florida last week. He moved into his new house here in Blowing Rock just yesterday.   EMS brought him in about ten minutes ago with shallow respirations and angina. Before we knew it, he was in cardiac arrest.”

All of the questions I had streaming through my brain clogged up and were replaced with a quick nod. Answering would have risked exposing my incredible lack of expertise. This was my first time. Even if I had been able to pull out a factoid on cardiac arrest, I’m not sure I would have been able to speak. I had never seen someone so close to the brink of death. Or was he dead already?

“Justin. Up here. Need to watch this.” Dr. Burch sounded exhausted as he beckoned me towards the bedside. He rushed each sentence into its own exhalation as if he was in the middle of a sprint.

The man had been shielded by nurses before I walked up to the bed; this was my first glimpse. The man’s face was extraordinarily cyanotic; not the dark red and blue cyanosis medical students see in textbooks, but a rich dark purple with shades of black creeping in. One eye was half open and the other completely closed. I looked for signs of a human eye under the open eyelash, but only found colorless sclera.  The chest looked nothing like any chest I had examined in my standardized patients. When I checked for heaves over the chest of simulated patients in class, my hand gently sat over the mediastinum as I inspected body landmarks I was trained to find.  Yet this man’s mediastinum was oddly sunken in, and I couldn’t find any landmarks. I noticed Dr. Burch’s hands were sinking deep into the chest with each compression; the man’s ribs were broken.

“Should we call it?”

“No. No not yet”

I paused my physical inspection to glance at the monitor. Still no pulse. This man was dying. Or should I call it dead? I resumed my visual exam from proximal to distal. The left hand was hanging off the bed and collecting uncirculated blood as it swung with a pendulous rhythm to Dr. Burch’s compressions.  The feet were much the same- lifeless and flailing at the mercy of violent attempts to bring the heart back to life. This man was dead.

The startling swing of the double doors drew my attention from the oscillating body parts as another nurse stormed in. I stepped back to let her take my place.  As I resumed my place against the wall, the double doors continued to swing open towards the outside hall, and then back again towards the emergency room. I glanced at the doors with furrowed brows- as if I could intimidate them into stopping. The doors were protecting the outside world from the death occurring in this room, and only those of us in the room should be burdened with the scene that was before us. As the door swung inward for the last time, I caught a quick snapshot of the women down the hall. Had she been staring at me the whole time the doors were swinging? She didn’t want the burden of seeing what I was. Thankfully the walls blocked her view. Only the few who were in the room had the privilege to be present for this man’s most private moment.  I decided I should look professional. I straightened my back and pulled down my sleeves.

“Calling it. 10:47.” My first death.

Some of the nurses began to cry as they started to clean up. Dr. Daniels and Dr. Burch immediately began paperwork at the small table beside the man’s bed. Several gloves were lying on the floor beside me and as I threw them away, I wondered if this would be a moment I would remember for the rest of my life; I hoped so.  I remembered a medevac EMT once told me that they hope no one gets hurt, but if someone does, they hope it’s on their shift.  I had just experienced yet another inauguration into the fraternity of healthcare.  I was glad this was my community week. I was glad I had left Mrs. Evnoy behind.  If this man had to die today, I was glad I was there for it. I stood by the trashcan in the middle of the trauma room proud of where I was. I had chosen an occupation where I will stand beside people at their most intimate, vulnerable moments.  As horrible as the scene had been, I walked towards the door with sobered excitement. I tried to look professional.

I moved to push the swinging door open; death had left the room, the somber scene subsided even further as a nurse cracked a joke. It was safe to open the doors now.

“Justin. Hold on, I need you to come with me to take care of something real quick.”

I removed my hand from the door and bounded over to Dr. Burch. I was eager to get him alone in his office so I could tell him how I oddly felt privileged, humbled and gratified for the scene I had just witnessed.  He was walking the wrong way though.

“Out here in the hall.”

I walked within him through the double doors, again trying to get maximum lift out of my coat tail. We continued the walk down the hall as I contemplated when I should begin to speak.  Suddenly Dr. Burch stopped short. I quickly spun around to see what had held him up.

Her eyes were locked with Dr. Burch’s own when I turned around.  The square face I had seen sitting in the hall earlier now looked long, the skin beneath her eyes sagged as she looked up. Her hand was frail, but full of color, as it reached up to grasp her gold cross necklace.  I noticed a large wedding ring on her finger. Dr. Burch gently placed his hand on her shoulder and looked down at his feet. Her eyes didn’t move.  I realized why we were in the hall. No way had Dr. Burch brought me along for this…

“I’m sorry. He didn’t make it.”

She began to cry. Unlike the movies I had seen where people shake uncontrollably or throw things in anger, this woman simply and authentically cried. Yet I had never seen or felt so much despair behind a cry. She grabbed on to Dr. Burch’s hand as he stroked her back.  I watched her tears trace the lines of her face downwards, falling off her chin and onto her hand below. She was wearing a charm bracelet with gold crosses that matched her necklace and earrings.  I thought it looked like something a husband might buy for his wife.

“I should have…I should have brought him in earlier… He told me his stomach hurt all day. It’s my fault isn’t it?”

“No ma’am. Sometimes these things happen and there is no great reason and no one can predict it.” Dr. Burch continued to rub her back.

“We just moved up here. He just retired. I could have saved him. I know I could have saved him.”  She grasped her necklace. I felt certain her husband had given it to her.

Her. Husband. She looked at me for the first time since I was in the ER. I didn’t look back.  I wanted to back away.  I wanted to run away.  I stared at a line between cinder blocks on the wall instead.  I examined a one inch section of mortar with every bit of my attention.  Otherwise, I would have likely broken into tears along with her.  I remembered how Dr. Burch had told me to come “watch.”  I was invited to watch an event that every medical student must encounter before graduating to the next level.  But it was not watching a body lose its myocardial electrical impulses. I had watched a husband die. I was watching a life torn apart.

 

I narrowed my eyes onto the concrete and tried to wonder how many bricks were stacked on top of each other.

Likely she and her husband had a date planned for the night. They had just moved into their retirement house.

I began to actually count the bricks from bottom to top.

I wondered if they had their first breakfast in their new house this morning. I imagined the husband reading a paper in his recliner and his wife squeezing in beside him in what little space was left.  They had no idea this was coming.  She had no idea what finality she was about to face.

I recounted bricks from top to bottom.

I wondered what that next night would be like in her house.  Would she be able to sit in his recliner? His stuff would be lying around exactly where he last laid it. Would she actually try to clean? I think I would leave it all in its place to pretend like nothing had happened.  Would she sleep in their bed tonight?  What if she woke up in the middle of the night and tried to put her arm around him?

With that thought my brick counting could no longer keep up with my thoughts. My eyes began to tear.  I blindly thought about the upcoming football game and who I should start in fantasy football; at this point, regaining my composure for the sake of this woman was worth sacrificing self-respect.

 

“Here is something for your nerves. Do you know where the drug store is?” Dr. Burch handed her the prescription.

“No. I’ve been here one day.”

“That’s OK.  I’ll get a nurse to draw you out a map.”

“Do you have anyone you can call? Any family?”

“No, we are the only ones… we were the only ones,” she slowly corrected.

“Oh…well.  Things are going to be hard at first, but they will get better.  I promise.  It’s hard to lose someone like this.  I’m going to write down the name of a counselor down the mountain in Boone that you might want to give a call tomorrow.”

With that Dr. Burch walked off towards his office.  I turned to follow but passed by him and stormed towards the study room in disgust of myself and our departure from the situation. I have no idea how “high” my “coat tail” was in the back.  In fact, I ripped my coat off before I made it to the patient waiting area; I didn’t want anyone to see me in it. For the first time, I questioned if I was ready to wear such a symbol of responsibility. I wished I had never left Mrs. Evnoy.

 

By Justin Miller